Affidavit Health Insurance (05/11)Page 1 of 1TC-38Hr

CONFIRMATION OF HEALTH AND/OR LONG TERM CARE INSURANCE PREMIUMS
Unit#:
Date:
Resident:______/ Phone: Fax:
Email:
Please complete one of these forms for EACH medical insurance provider
Please attach a copy of your medical insurance premium statement, coupon booklet, copies of cancelled checks or bank statements in date order, showing the amount and frequency of premium payments made per year.
If your premium costs are increasing from the prior year, please attach proof of this increase. Forms of proof may include but are not limited to, a copy of the notification letter from the insurance provider, a newly issued coupon booklet, etc.
Health Insurance
Name and address of provider
Premium Paid (check one) / □ Monthly □ Bi-monthly □Quarterly □Semi-annually □Annually
Premium amount paid / $ X = $
Long Term Care Insurance
Name and address of provider
Premium Paid (check one) / □ Monthly □ Bi-monthly □Quarterly □Semi-annually □Annually
Premium amount paid / $ X = $
I hereby certify that the Long-term Care Insurance for which I pay meets the following conditions:

Is guaranteed renewable;
Does not provide a cash surrender value which can be paid, assigned, pledged or borrowed;
Must provide that refunds, other than refunds on the death of the insured or complete surrender or cancellation of the contract, and dividends under the contract may be used only to reduce future premiums or increase future benefits; and

Generally must not pay or reimburse expenses incurred for services or items that would be reimbursed under Medicare (except where Medicare is a secondary payer or the contract makes per diem or other periodic payments without regard to expenses).
I hereby certify that the information stated above is true and correct to the best of my knowledge and belief. Inquiries may be made to further certify this information. I have also read and understood the penalty/warning statements enclosed.
Applicant/Resident Signature: / Date:
Signature must be witnessed below
Witness my signature this day of 20
Printed Name:
Signature of Witness:
PLEASE READ THE STATEMENT BELOW CAREFULLY BEFORE SIGNING THE VERIFCATION FORM
Warning: Section 1001 of Title 18, United State code provides: “Whoever, in any matter within any jurisdiction of any department or agency of the United States Knowingly or willfully falsifies, conceals or covers up… a material fact, or makes any false, fictitious or fraudulent statements or representation, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.”

Affidavit Health Insurance (05/11)Page 1 of 1TC-38hr