CNA Long-Term Care Insurance

Form Name
First
Last
Email
Phone
Address 1
Address 2
City
State
State
Zip
Insured under a long-term care policy?
If other company, please select:
Did your premium increase?
If so, by what percentage?
Policy start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you filed a claim on this policy?
If so, was it approved?
Is your policy currently active?
If not active, enter end date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State of residence
Insurance purchased through employer or individual policy?
Employer name
Employer size
State where employer is headquartered
Rate increase of employer home state
Did you purchase inflation protection?
Additional information:
By submitting this form, you are opting in to receive emails from Hagens Berman about this case. Set the others to your preference.
By submitting this form, you are opting in to receive emails from Hagens Berman and their co-counsel about this case. Set the others to your preference.
By submitting this form, you acknowledge our Notice at Collection.
Should be Empty: