Long Term Care Enrollment Forms

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All forms and notices on this web site are saved in Adobe PDF format. If needed, download Acrobat Reader from Adobe's website. (Please note: Earlier versions of Acrobat Reader will allow you to view these files. However, when you're viewing multiple PDF files, you may receive the error "Maximum number of files are already open." Close the Acrobat Reader icon at the bottom of your screen. When you view the next file, Acrobat Reader will re-open automatically refreshed.)

If you would like to receive a copy of all of the enrollment forms in Adobe's PDF format, please enter your email address in the form below and click the "Send" button. You'll receive an email with eleven PDF documents attached and instructions on how to fill them out. The email address below is: An employee of City Bank A relative of a City Bank employee

1. Review Your Plan Details Familiarize yourself with the details of your plan. CityBank's Plan Details A list of the rates associated with your plan options. Rates 2. Important Information About Your Enrollment Read and print for your records. These are for information only. Nothing in this section needs to be completed and sent into Unum. Plan Highlight Outline of Coverage Replacement of Existing Coverage (1638-94(3/00)) Medicare Notice (1504-95(3/98)) Notice of Termination (1311-96(1/99)) Life and Health Guaranty Association Notice (1343-92) Things You Should Know About Long Term Care (1375-96)

HOW TO ENROLL 3. Employee Enrollment Print out the forms below. Complete, save a copy for your records, and submit these forms to: Human Resources 201 Merchant Street Honolulu, HI 96813 Forms Description Enrollment Form Complete this form and submit it to Group Long Term Care at the address listed above. Long Term Care Insurance Application (1050-00) (medical questionnaire) You must complete this form if you enroll after the Guarantee Issue enrollment period (more than 30 days following your company benefit eligibility date), or choose benefits over the Guarantee Issue limits ($4,000 Facility Benefit Amount or Unlimited Benefit Duration), you will be required to fill out Unum's Long Term Care Insurance Application (medical questionnaire). Nursing Home Insurance Personal Worksheet (1237-96) State Law requires that you complete this worksheet. 4. Spouse Enrollment All spouse coverage is medically underwritten. The Long Term Care Insurance Application (1050-00) must be completed. To apply for coverage, print and complete the Family Enrollment Form and the Long Term Care Insurance Application (1050-00), then call the Enrollment Line at 1-888-376-7655. Complete these forms and mail them to: Group Long Term Care - A206, Unum Life Insurance Company of America, 2211 Congress Street, Portland, ME 04122. 5. Retiree and Family Enrollment All other eligible family members who would like to apply for coverage may contact Unum toll-free at 1-800-227-4165 for more information and/or to receive an enrollment kit.

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Updated December 2001

Underwritten by:
Unum Life Insurance Company of America
2211 Congress Street
Portland, Maine 04122

Unum is the marketing brand of UnumProvident Corporation. ©2001 UnumProvident Corporation. Unum®, the lighthouse artwork and "Protecting everything you work for®" are registered trademarks of UnumProvident Corporation. All rights reserved.

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