The “Authorization for Disclosure of Protected Health Information Related to an Adverse Underwriting Decision” form (#NLTC-0324) is an optional form that, when completed and signed by the EssentialLTC applicant(s), allows the underwriter to share additional information regarding an adverse underwriting decision with the agent and/or their marketing organization.

In order to make access to this form easier, effective July 2, 2018 this form will be made available as part of the EssentialLTC application documents for each state. To access the form in the EssentialLTC Agent Resource Center, select the “New Business” tab followed by “Applications and Forms,” and select the appropriate state in the “State-Specific Applications & Forms” dropdown. The Adverse Underwriting form will be available under the Optional application documents.
 
Please call NGL’s Agent Resource Center (888-505-2332) if you have any questions or would like additional information.
 
Adverse Underwriting Form now available as part of Application Documents
 
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