Long Term Care Insurance Forms

Browse Genworth’s collection of long term care insurance forms below. Once you locate the appropriate long term care insurance form, download and complete in full. Once you’ve printed it out, please sign and return it to the address found directly on your long term care insurance form. If you have not already done so, please download Adobe Reader® to view the forms.

Are you looking for one of these forms?

These are the top three most downloaded long term care insurance forms. We've listed them here for your convenience. If the form you are looking for is not one of these three, all other long term care insurance forms are listed on this page, below.

Electronic funds transfer (EFT) authorization

Address, name or third party changes

Health information authorization

Genworth’s long term care insurance forms will assist you with conducting authorizations, changing your name/address, naming a beneficiary, changing your long term care coverage and conducting other updates to your account.

Address, name or third party changes
Submit address or name changes for yourself or other parties on your policy, or to add, change or delete a third party listed on your policy.

Electronic funds transfer (EFT) authorization
Request automatic withdrawals from your bank account to pay premiums on long term care insurance policies, or to update bank account information for policies already drafting premiums. 

Health information authorization
An authorization form allowing us to share your health history and related health information with a third party, whom you've designated. 

Coverage change request form 
This form is used to request benefit changes and/or change the payment frequency on a current long term care insurance (LTCI) policy. 

Long Term Care Insurance request for beneficiary change 
Use this form to change the beneficiary on an existing Long Term Care Insurance policy, that has a Return of Premium Rider.

Deferred annuity to LTCI 1035 transfer authorization
Use this form to authorize an exchange from a non-qualified deferred annuity contract to a Long Term Care Insurance policy 

Immediate annuity to long term care insurance funding request for existing immediate annuity contracts with irrevocable assignment 
Use this form to certify that all or the specified portion of your non-qualified immediate annuity payment will directly fund your LTCI policy. 

Life insurance to LTCI 1035 transfer authorization 
Use this form to authorize an exchange from a non-qualified life insurance policy to a long term care insurance policy.

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129277LTC 08/15/14