Revised Pre-Authorized Premium Paying Service forms
The “Pre-Authorized Check (PAC) Premium Payment Service forms used to request ongoing PAC premium payments for the EssentialLTC Product have been revised effective October 1, 2021. There are two versions of this PAC form, which vary by state.
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Form Name: |
New Form Number: |
Replaced Form Number: |
Form utilized in: |
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Pre-Authorized Check (PAC) Premium Payment Service |
ICC16-NLTCAPA 09/21 |
ICC16-NLTCAPA |
Compact Approved states: AK, AL, AR, CO, GA, IA, ID, IL, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, NE, NH, NM, NV, OH, OK, OR, PA, RI, SC, TN, TX, UT, VA, VT, WA, WI, WV, WY. |
|
Pre-Authorized Check (PAC) Premium Payment Service |
NLTCAPA 09/21 |
NLTCAPA |
Non-Compact approved states: AZ, CA, CT, DE, DC, FL, HI, IN, NJ, ND, SD. |
The updated PAC forms will be available on the EssentialLTC Agent Resource Center under each state specific application documents on September 24, 2021. This can be accessed by selecting the “New Business” tab and selecting the appropriate state from the “State-Specific Applications and Forms” dropdown.
The new Pre-Authorized Check forms must be utilized for applications and new PAC form requests signed and dated October 1, 2021 and after.
For agent inquiries contact your dedicated NGL Agent Services Team at 888.505.2332 or status@ngl-essentialltc.com. For sales questions contact the NGL Long-Term Care Sales Team at LTC@nglic.com.
Revised Pre-Authorized Premium Paying Service forms
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