Notice of Long Term Care Claim

Use this notice to inform Northwestern Mutual Long Term Care Company of your request for long term care benefits. Upon receipt we will prepare a personalized claim kit and send it to the Insured or the Insured's Power of Attorney if applicable.

Note: To be eligible for long-term care benefits, you must have a 90 consecutive day need for long-term care services requiring either hands-on or stand-by assistance with at least 2 of 6 Activities of Daily Living (eating, toileting, transferring, bathing, dressing or continence) or substantial supervision to protect your health and safety due to a severe cognitive impairment.

If you have any questions, call Client Services at (800) 748-9493, between and CST.

All fields marked with * are required.

Notice of long term care claim form
Insured Information

Insured Information

Claim Contact

Claim Contact

Best Person to Contact
Note: The Power of Attorney document will be reviewed when it is received by NLTC. Please fax the POA to 414-625-1526 and include the LTC policy number and name of the insured on the fax cover page.
Insured or Power of Attorney Mailing address

Mailing Address

Long Term Care Information

Primary care provider information

Primary Care Provider Mailing address

Mailing Address

Indicate if assistance with Activities of Daily Living (ADL) is required
Indicate if substantial supervision for a Cognitive Impairment is required:
Formal Services Information
Other Insurance

Other Insurance

Other LTC Insurance
Northwestern Mutual Group Disability Insurance
Long Term Care Notification Completed by

Long Term Care Notification Completed by

Notification completed by