Form 1099-LTCThis field is hidden when viewing the formUser Logged In?Create Form 1099-LTCThis field is hidden when viewing the formForm 1099-LTCSelect Tax Year*2023How many 1099 forms you need?1234This field is hidden when viewing the formContact InfoEmail* Already have an account? Login now.Payer's InfoPayer's Name*Payer's Tax ID*Payer's Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policyholder’s InfoPolicyholder’s Name*Policyholder’s Tax ID*Policyholder’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account numberMay show an account or other unique number the payer assigned to distinguish your account.Please enter a number greater than or equal to 0.Gross long-term care benefits paidAccelerated death benefits paidCheck one: Per diem Reimbursed amount Qualified contract Qualified contract Check, if applicable (optional): Chronically ill Terminally ill Insured’s InfoInsured’s Name*Insured’s Tax ID*Insured’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date certified MM slash DD slash YYYY Second Policyholder’s InfoSecond Policyholder’s Name*Second Policyholder’s Tax ID*Second Policyholder’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account numberMay show an account or other unique number the payer assigned to distinguish your account.Please enter a number greater than or equal to 0.Gross long-term care benefits paidAccelerated death benefits paidCheck one: Per diem Reimbursed amount Qualified contract Qualified contract Check, if applicable (optional): Chronically ill Terminally ill Second Insured’s InfoSecond Insured’s Name*Second Insured’s Tax ID*Second Insured’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date certified MM slash DD slash YYYY Third Policyholder’s InfoThird Policyholder’s Name*Third Policyholder’s Tax ID*Third Policyholder’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account numberMay show an account or other unique number the payer assigned to distinguish your account.Please enter a number greater than or equal to 0.Gross long-term care benefits paidAccelerated death benefits paidCheck one: Per diem Reimbursed amount Qualified contract Qualified contract Check, if applicable (optional): Chronically ill Terminally ill Third Insured’s InfoThird Insured’s Name*Third Insured’s Tax ID*Third Insured’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date certified MM slash DD slash YYYY Fourth Policyholder’s InfoFourth Policyholder’s Name*Fourth Policyholder’s Tax ID*Fourth Policyholder’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account numberMay show an account or other unique number the payer assigned to distinguish your account.Please enter a number greater than or equal to 0.Gross long-term care benefits paidAccelerated death benefits paidCheck one: Per diem Reimbursed amount Qualified contract Qualified contract Check, if applicable (optional): Chronically ill Terminally ill Fourth Insured’s InfoFourth Insured’s Name*Fourth Insured’s Tax ID*Fourth Insured’s Address* Street Address City Select StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date certified MM slash DD slash YYYY This field is hidden when viewing the formPDF PreviewClick refresh icon to see changes to the pdf.PDF Preview Full Screen Rotate your phone sideways for larger preview.PDF Preview Full Screen Rotate your phone sideways for larger preview.PDF Preview Full Screen Rotate your phone sideways for larger preview.PDF Preview Full Screen Rotate your phone sideways for larger preview.Select 1099 to previewFirst PolicyholderSecond PolicyholderThird PolicyholderFourth PolicyholderThis field is hidden when viewing the formTotalTotal $0.00 100% Money-Back Guarantee Complete satisfaction guarantee or your money back. Select 1099 PDF to previewFirst PolicyholderSecond PolicyholderThird PolicyholderFourth PolicyholderPDF Preview Full Screen Rotate your phone sideways for larger preview.PDF Preview Full Screen Rotate your phone sideways for larger preview.PDF Preview Full Screen Rotate your phone sideways for larger preview.PDF Preview Full Screen Rotate your phone sideways for larger preview.This field is hidden when viewing the formShow Modal Checkout Almost there! Complete checkout to receive your PDF without watermarks or restrictions. Click “Previous” if you still have some edits to make.Checkout Now 100% Money-Back Guarantee Complete satisfaction guarantee or your money back.
