CGR

(Rev 09/2016)

Independent Care Provider Formfor Digital Time Card Mobile App Registration

____________________________

____________________________

Insured’s Name:

Policy Number:

Claim Number: ____________________________

If the caregiver being utilized has not previously provided this information to us, or the information previously provided has changed, he or she will need to complete and return this form to the address or fax number provided. In addition, should there be multiple independent caregivers, each care provider must complete a separate form.

I. Independent Care Provider Information:

Provider’s Name (Last, First Middle): Relationship to Insured: Date of Birth:

Type of Care Provider:

Nurse Therapist Aide Companion Homemaker Other: ________________________

Shift Rate:

Provider’s Home Address: City: State: ZIP:

Provider’s Email Address: Provider’s Tax ID / SSN (Last 4):

Primary Phone:

Home Work Cell

Phone Number:

II. Valid United States Federal or State Government Issued Photo Identification (in lieu of Tax ID/Last 4 of SSN)

Type of Identification: ID Number: Expiration Date: State/Country of ID:

III. Fraud Notice

III. Signature

Signature of Independent Care Provider:

Date:

† Only Genworth Life Insurance Company of New York is admitted in and conducts business in New York.

Mail Address:

Fax Number: Phone Number:

Genwor th Life & A nnuity Insur ance Com pany, Genworth Life Insurance Company, Genworth Life Insurance Company of New York†

Attn: LTCI Claims P.O. Box 40007, Lynchburg, VA 24506-9939 888 557.5526 800 876.4582

Visit Us Online: www.genworth.com/login.html

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.