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 claim representative if applicable.

Note: To be eligible for long-term care benefits, you must have a 90 consecutive day or longer need for long-term care services requiring either hands-on or stand-by assistance with at least 2 of 6 Activities of Daily Living and/or Substantial Supervision to protect your health and safety due to severe cognitive impairment.

The 6 Activities of Daily Living include:

  • Eating
  • Toileting
  • Transferring
  • Bathing
  • Dressing
  • Continence

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

Reason for Claim

Reason for Claim

Indicate if assistance with Activities of Daily Living (ADL) is required
Indicate if substantial supervision for a Cognitive Impairment is required:
Claim Contact

Claim Contact

Best Person to Contact
Mailing Address for insured or insured's representative

Mailing Address for insured

Note: The Power of Attorney document will be reviewed when it is received by NLTC. Please include the LTC policy number and insured name on the POA document copy and send:

Long Term Care Information

Primary Care Physician Information

Primary Care Provider Mailing address

Mailing Address

Formal Services Information

Formal Care Services

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