Start My Claim Assistance

Welcome to Affirm Assist-Start Claim Assistance

This secure form helps us gather the information we need to begin managing your monthly long-term care submissions.We handle the deadlines, paperwork, and uploads — so you can focus on what matters most.

What is your Full Name

First NameLast Name
Email
example@example.com
Email (Confirm Email)
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Are you completing this form for yourself or for someone else?
If completing this form for someone else, what is your relationship to the client?
Will you be the Primary contact for the monthly claim submissions?

Policy Holder Information
Full Name of Policy Holder

First NameLast Name
Policy Holders Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holders Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policy Information
Who is your Long Term Care Insurance Company?
Policy Number
Policy start date?

Current Claim Status?

Who currently receives the monthly claim forms from the insurance company?
What is requiered to submit claims paperwork? ( Select all that apply)

How are monthly claim forms currently being submitted? (Submission Methods) (Select All that Apply)

What is the current plan of care?

What would it mean to you if Affirm Assist handled everything for you?

How soon would you like us to begin managing your monthly submissions?

Please Upload A Copy of Your Long Term Care Benefits Claim Form

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Would you like your insurance company to send monthly forms directly to Affirm Assist? (Requires POA or an authorized representative form.)

Do you have Power of Attorney documentation?

If Yes: Please Upload POA Document ( if available )

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Upload Any Important Policy Documents

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Optional Comment Box ( Tell anything else you need us to know)

“I consent to Affirm Assist securely collecting my information for the purpose of claim support. I understand Affirm Assist is not a law firm or insurer.”

Your Information Has Been Received

Thank you for trusting Affirm Assist.
Your onboarding specialist will reach out shortly via email.

Please make sure to check all your inboxes just in case our email does not land in your primary inbox (including spam/junk) as we will need to reach out via email.

We’re committed to making your long-term care claims easy, accurate, and stress-free — every single month.
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