Instructions for Policyholder
A payer, such as an insurance company or a viatical settlement provider, must
give this form to you for payments made under a long-term care insurance
contract or for accelerated death benefits. Payments include those made
directly to you (or to the insured) and those made to third parties.
A long-term care insurance contract provides coverage of expenses for long-
term care services for an individual who has been certified by a licensed health
care practitioner as chronically ill. A life insurance company or viatical settlement
provider may pay accelerated death benefits if the insured has been certified by
either a physician as terminally ill or by a licensed health care practitioner as
Long-term care insurance contract. Generally, amounts received under a
qualified long-term care insurance contract are excluded from your income.
However, if payments are made on a per diem basis, the amount you may
exclude is limited. The per diem exclusion limit must be allocated among all
policyholders who own qualified long-term care insurance contracts for the
same insured. See Pub. 525, and Form 8853 and its instructions for more
Per diem basis. This means the payments were made on any periodic basis
without regard to the actual expenses incurred during the period to which the
Accelerated death benefits. Amounts paid as accelerated death benefits are
fully excludable from your income if the insured has been certified by a
physician as terminally ill. Accelerated death benefits paid on behalf of
individuals who are certified as chronically ill are excludable from income to the
same extent they would be if paid under a qualified long-term care insurance
Policyholder's taxpayer identification number (TIN). For your protection, this
form may show only the last four digits of your TIN (social security number
(SSN), individual taxpayer identification number (ITIN), adoption taxpayer
identification number (ATIN), or employer identification number (EIN)). However,
the issuer has reported your complete TIN to the IRS.
Account number. May show an account or other unique number the payer
assigned to distinguish your account.
Box 1. Shows the gross benefits paid under a long-term care insurance contract
during the year.
Box 2. Shows the gross accelerated death benefits paid during the year.
Box 3. Shows if the amount in box 1 or 2 was paid on a per diem basis or was
reimbursement of actual long-term care expenses. If the insured was terminally
ill, this box may not be checked.
Box 4. May show if the benefits were from a qualified long-term care insurance
Box 5. May show if the insured was certified chronically ill or terminally ill, and
the latest date certified.
Future developments. For the latest developments related to Form 1099-LTC
and its instructions, such as legislation enacted after they were published, go to