CalPERS Long-Term Care Program CLAIM INTAKE PACKET

CalPERS Long-Term Care Program

CLAIM INTAKE PACKET

Thank you for contacting CalPERS Long-Term Care Program regarding your recent request for benefits.

Attached is a Claim Intake Packet. The enclosed Information Page explains what forms must be

completed and submitted in order to proceed with your claim request.

In order to determine your eligibility for benefits, we may require that an in-person assessment be

performed. The assessment, if required, will be performed by a care advisor. If you have not already

received a call, they will be calling you shortly to arrange for an in-person assessment interview at a time

that is convenient for you. Your cooperation in scheduling this interview as soon as possible is greatly

appreciated.

Your claim form and other required documents must be completed and returned in order to begin

processing your claim. If you recently submitted these documents to us, please disregard. You may return

the completed forms to us via fax to 1-866-294-6967 (preferred) or mail them to CalPERS Long-Term

Care Program, P.O. Box 64902, St. Paul, MN 55164.

If you have any questions regarding this request, please call our Claims Representatives at 1-800-982-

1775, between 8:00 a.m. and 6:00 p.m. Pacific Time. , or e-mail us at [email protected]

Sincerely,

Claims Department

LTCG - Administrator for CalPERS Long-Term Care Program


INFORMATION PAGE Required: The following forms are required to be completed and signed

CalPERS Long-Term Care Program Claim Form

Please complete the form to the best of your knowledge, sign and return.

Authorization Form This authorization permits us to obtain records from your provider.

Optional: The following forms are optional, please complete if applicable

Third Party Authorization Form

Sign and return to authorize another person to discuss your claim and/or represent you during the claim process.

Direct Deposit Form Sign and return if you want your benefits deposited directly into your bank account.

Assignment of Benefits Form Sign and return if you want benefits to be paid directly to your provider.


LONG-TERM CARE CLAIM FORM

Instructions: The claim form is required to determine your eligibility for benefits. Please complete the form to the best of your knowledge. Please sign and return the completed form via fax to 1-866-294-6967 (preferred) or mail to: CalPERS Long-Term Care Program, P.O. Box 64902, St. Paul, MN 55164.

Section 1: Claim Contact Information

________________________________________________________________________________________ Claimant Name Coverage ID Number _________________________________________/____/_____________________ xxx-xx-_______________ Other name(s) known by Date of Birth Last 4 of Social Security # ________________________________________________________________________________________ Address City State Zip Code _______________________________________________________________________ M F________ Phone Number Gender

________________________________________________________________________________________ Contact Person Name* (if unable to reach claimant) ________________________________________________________________________________________ Phone Number Relationship to Claimant *The above Contact Person must be either your attorney-in-fact or an Authorized Individual for whom you have submitted a Third Party Authorization Form for Use and Disclosures of Protected Health Information to an Authorized Individual/Personal Representative. Do you have an attorney-in-fact (person to whom you have given Power of Attorney), court appointed Conservator, or Legal Guardian? Yes No If yes, attach a copy of the legal documents (Power of Attorney, Conservatorship, or Legal Guardianship) to this claim form. If you have appointed more than one person to represent you, provide information on the other person(s) on a separate sheet of paper.

Please note that in accordance with The Health Insurance Portability and Accountability Act (HIPAA), we will not disclose information to individuals who do not hold Power of Attorney, who are not Authorized Individuals or are not your guardian/conservator.

Section 2: Care Needs Information

What is the reason(s) or condition(s) resulting in your need for long-term care? Please include date of occurrence/onset if applicable – if unknown, please estimate the onset of the condition Date of occurrence/onset: _____________________ Description: __________________________________________________________________________________

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

What other health conditions do you have that contribute to your need for assistance? ____________________________________________________________________________________________ ____________________________________________________________________________________________

What best describes your current living situation?

Lives with: Alone Spouse/Significant Other Other: ___________________

Location: Private Home Independent Living Facility Assisted Living Facility Memory Care Unit/Facility

Skilled Nursing Facility Hospital/Swing Bed Transitional Care/Rehabilitation Facility

Is there a spouse/significant other in claim? Yes No

Section 3a: Activities of Daily Living

Typical long-term care services are assistance with daily activities, like bathing, dressing, using the toilet, etc., or needing supervision due to a cognitive impairment. Indicate the current level of assistance needed with the following Activities of Daily Living (ADLs). Use the following guide to indicate the level of assistance being provided on a regular basis:

1 = No assistance is provided, claimant is Independent

2 = Uses equipment, does not receive assistance from another person

3 = Receives cueing/prompting to initiate or complete the ADL due to memory loss

4 = Receives stand-by assistance (person within arm’s reach) from another person to complete the ADL

5 = Receives hands-on assistance from another person to complete some or all of the ADL

6 = Unable to participate in any part of the ADL

ACTIVITIES OF DAILY LIVING

Level (use key above)

Frequency How do you complete activity

when alone?

Bathing Always Daily Occasional Weekly

Dressing Always Daily Occasional Weekly

Toileting Always Daily Occasional Weekly

Transferring Always Daily Occasional Weekly

Incontinence Always Daily Occasional Weekly

Eating (does not include meal prep.)

Always Daily Occasional Weekly

Mobility/Ambulation (indoors only)

Always Daily Occasional Weekly

Describe in more detail what assistance you need with any activities marked above.

If durable medical equipment is used, please describe the type of equipment and when this is needed: ______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Section 3b: Instrumental Activities of Daily Living (Homemaker Services)

Please fill out the section below if the policyholder is receiving assistance with any activities or tasks beyond basic care

that allow the policyholder to live independently.

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

Assistance Needed?

Comments

Housekeeping Yes No

Laundry Yes No

Meal Preparation Yes No

Medication Reminders Yes No

Money Management Yes No

Shopping Yes No

Social Companionship Yes No

Telephone Use Yes No

Transportation Yes No

Other ________________ Yes No

Section 4: Cognitive Impairment

Only fill this section out if policyholder has a cognitive impairment. If claimant does not have a cognitive impairment,

please check “No” and proceed to next page.

Does policyholder have cognitive impairment? Yes No Undetermined

If Yes, please fill in section below.

Is there a known formal diagnosis of cognitive impairment? Yes No Undetermined If yes, please list cognitive impairment diagnosis:______________________________________ Date of diagnosis:____________________

Has formal cognitive testing been completed? Yes No Undetermined

If yes, when was testing completed? _____________________________________

List any Dementia Medications: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

List any additional information related to the claimant’s cognitive behavior:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Section 5: Other Insurance Information

Only fill this section out if there is additional insurance coverage for payment of this claim. If no other coverage exists,

please check “No Medicare coverage or Supplemental Insurance” and proceed to next page. No Medicare coverage or Supplemental Insurance

Medicare Insurance Type: Part A Part B Part D

Other Insurance for this Claim (Please attach additional pages if necessary) Medicare Supplemental Insurance/Medigap Health Other Long-Term Care Policy: Group Individual Veterans Affairs (VA) Medicaid or MediCal Liability insurance (automobile, homeowners, liability, workers’ compensation, or disability insurance) ____________________________________________________________________________________ Carrier Name ____________________________________________________________________________________ Policyholder Name ____________________________________________________________________________________ Address ____________________________________________________________________________________ City State Zip Code _________________________________ Phone _________________________________ ______________________________ Policy Number Coverage ID _________________________________ ______________________________ Effective Date Expiration Date

Section 6: Third Party Liability

Has there been an injury, fall, fracture, or motor vehicle accident that resulted in filing a claim with another insurance carrier? Yes No

Section 7: Medical Provider and Hospitalization Information (Please attach additional pages if necessary)

Physician Information

___________________________________________________________________________________________ Name of Physician Specialty (if any)

___________________________________________________________________________________________ Address

___________________________________________________________________________________________ City State Zip Code

_________________________ _________________________ Phone Fax

Physician Information

___________________________________________________________________________________________ Name of Physician Specialty (if any)

___________________________________________________________________________________________ Address


_________________________ _________________________ Phone Fax

Are you currently hospitalized, or have you been hospitalized within the last 6 months?

___________________________________________________________________________________________ Hospital Name

___________________________________________________________________________________________ Address


_________________ _________________ ____________________________________________________ Admission Start Date Admission End Date Reason for Admission

Section 8: Service Provider Information (Please attach additional pages if necessary)

Please list any service providers that are or have recently provided long-term care services to you.

Check Provider Type:

___________________________________________________________________________________________

Name of Provider

___________________________________________________________________________________________ Address


_________________________ _________________________ Phone Fax

_________________________ _________________________ Date Services Started Date Services Ended

Home Health Agency/Home Care

Agency

Skilled Nursing Facility

Adult Day Care

Independent Living Facility Hospice Facility

Assisted Living Facility Hospice Agency


___________________________________________________________________________________________

Name of Provider

___________________________________________________________________________________________ Address


_________________________ _________________________ Phone Fax



Agency


Adult Day Care




___________________________________________________________________________________________

Name of Provider

___________________________________________________________________________________________ Address


_________________________ _________________________ Phone Fax



Agency


Adult Day Care



Section 9: Claim Fraud Warning Statements Before signing this claim form, please read the warning for the state where you reside and for the state where the insurance policy under which you are requesting a claim was issued. AL: Any person who knowingly presents a false or fraudulent claim

for payment of a loss or benefit or who knowingly presents false

information in an application for insurance is guilty of a crime and

may be subject to restitution fines or confinement in prison, or any

combination thereof.

AK: A person who knowingly and with intent to injure, defraud, or

deceive an insurance company files a claim containing false,

incomplete, or misleading information may be prosecuted under state

law.

AZ: For your protection Arizona law requires the

following statement to appear on this form. Any

person who knowingly presents a false or fraudulent

claim for payment of a loss is subject to criminal

and civil penalties.

AR, LA, RI, TX and WV: 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.

CA: For your protection California law requires the following to

appear on this form: Any person who knowingly presents false or

fraudulent claim for the payment of a loss is guilty of a crime and

may be subject to fines and confinement in state prison.

CO: It is unlawful to knowingly provide false, incomplete, or

misleading facts or information to an insurance company for the

purpose of defrauding or attempting to defraud the company.

Penalties may include imprisonment, fines, denial of insurance and

civil damages. Any insurance company or agent of an insurance

company who knowingly provides false, incomplete, or misleading

facts or information to a policyholder or claimant for the purpose of

defrauding or attempting to defraud the policyholder or claimant with

regard to a settlement or award payable from insurance proceeds shall

be reported to the Colorado division of insurance within the

department of regulatory agencies.

DE, FL, ID, IN and OK: WARNING: Any person who knowingly,

and with intent to injure, defraud or deceive any insurer, files a

statement of claim containing any false, incomplete or misleading

information is guilty of a felony.

DC: WARNING: It is a crime to provide false or misleading

information to an insurer for the purpose of defrauding the insurer or

any other person. Penalties include imprisonment and/or fines. In

addition, an insurer may deny insurance benefits if false information

materially related to a claim was provided by the applicant.

KY: Any person who knowingly and with intent to defraud any

insurance company or other person files a statement of claim

containing any materially false information or conceals, for the

purpose of misleading, information concerning any fact material

thereto commits a fraudulent insurance act, which is a crime.

ME, TN, VA and WA: It is a crime to knowingly provide false,

incomplete or misleading information to an insurance company for

the purpose of defrauding the company. Penalties may include

imprisonment, fines or a denial of insurance benefits.

MD: Any person who knowingly or willfully presents a false or

fraudulent claim for payment of a loss or benefit or who knowingly

or willfully presents false information in an application for insurance

is guilty of a crime and may be subject to fines and confinement in

prison.

MN: A person who files a claim with intent to defraud or helps

commit a fraud against an insurer is guilty of a crime.

NH: Any person who, with a purpose to injure, defraud or deceive

any insurance company, files a statement of claim containing any

false, incomplete or misleading information is subject to prosecution

and punishment for insurance fraud, as provided in RSA 638:20.

NJ and NM: Any person who knowingly files a statement of claim

containing any false or misleading information is subject to criminal

and civil penalties.

NY: Any person who knowingly and with intent to

defraud any insurance company or other person

files an application for insurance or statement of

claim containing any materially false information,

or conceals for the purpose of misleading,

information concerning any fact material thereto,

commits a fraudulent insurance act, which is a

crime, and shall also be subject to a civil penalty not

to exceed five thousand dollars and the stated value

of the claim for each such violation.

OH and OR: Any person who, with intent to defraud or knowing

that he is facilitating a fraud against an insurer, files a claim

containing a false or deceptive statement material to the risk may be

guilty of insurance fraud.

PA: Any person who knowingly and with intent to defraud any

insurance company or other person files an application for insurance

or statement of claim containing any materially false information or

conceals for the purpose of misleading, information concerning any

fact material thereto commits a fraudulent insurance act, which is a

crime and subjects such person to criminal and civil penalties.

PR: Any person who knowingly and with the intention of defrauding

presents false information in an insurance application, or presents,

helps, or causes the presentation of a fraudulent claim for the

payment of a loss or any other benefit, or presents more than one

claim for the same damage or loss, shall incur a felony and, upon

conviction, shall be sanctioned for each violation with the penalty of

a fine of not less than five thousand (5,000) dollars and not more than

ten thousand (10,000) dollars, or a fixed term of imprisonment for

three (3) years, or both penalties. Should aggravating circumstances

are present, the penalty thus established may be increased to a

maximum of five (5) years, if extenuating circumstances are present,

it may be reduced to a minimum of two (2) years.

Section 10: Signature Page

I declare that all of the answers given are complete and true to the best of my knowledge and belief. I

understand that the company reserves the right to require further proof. By signing below, I agree that I

have read and understand the applicable Claim Fraud Warning Statements.

_________________________________________________________________________________________

Signature of Claimant or *Legal Representative Date signed (Month, Day, Year)

_________________________________________________________________________________________

Printed Claimant’s or Legal Representative’s Name Signed at (City, State)

_________________________________________________________________________________________

If Representative, give relationship to Claimant

*All signatures, other than that of the Claimant, must be identified and accompanied by appropriate documentation of

authority to represent the Claimant (for example: Durable Power of Attorney, Conservator, or Guardian).


AUTHORIZATION FORM

Instructions: By signing this form, you are giving us authorization to obtain records from your provider to determine your eligibility for benefits. Please complete and return this form via fax to 1-866-294-6967 (preferred) or mail to: CalPERS Long-Term Care Program, P.O. Box 64902, St. Paul, MN 55164.

Claimant Name: ___________________________________________________ Claimant Date of Birth: ____________________________ Coverage ID Number: ____________________________

I AUTHORIZE THESE PERSONS or institutions having any records or knowledge of me or my health:

Any physician, medical practitioner, or health care provider

Any hospital, clinic, pharmacy or other medical or medically related facility, or association

Any insurance company or insurance support organization

Any employer or plan administrator

Any government agency

Any organization or entity administering a benefit program

Any rehabilitation organization or program

Any financial institution, consumer reporting agency, accountant, or tax preparer

TO GIVE THIS INFORMATION: Chart notes, x-rays, operative reports, lab and medication records and all other medical information about me, including medical history, diagnosis, examinations, testing and test results, prescriptions, prognosis and treatment of any physical or mental condition including:

Any disorder of the immune system including HIV, Acquired Immune Deficiency Syndrome (AIDS) or other related syndromes or complexes. Note: In the state of Minnesota, this Authorization does not include the performance of, or the results of, a test to determine the presence of the Human Immune Deficiency Virus (HIV) antibody given to (a) an offender, as defined under Minnesota law; or (b) a crime victim because of exposure to, or contact with, such an offender.

Any communicable disease or disorder.

Any psychiatric or psychological condition, including test results.

Any condition, treatment, or therapy related to Substance Abuse, including Alcohol and Drugs; and

Any non-medical information including such things as eligibility for other benefits, earnings, or finances.

TO CalPERS Long-Term Care Program:

I understand that CalPERS Long-Term Care Program will use the information to determine my eligibility for benefits.

CalPERS Long-Term Care Program may release information about me to its affiliates, or any person performing business or legal services for CalPERS Long-Term Care Program in connection with my claim. I ACKNOWLEDGE THAT I HAVE READ THE AUTHORIZATION and I understand and agree that this authorization shall remain in force throughout the duration of my claim for benefits with CalPERS Long-Term Care Program. A photocopy of this authorization is as valid as the original.

I may revoke this authorization at any time by providing written notice to CalPERS Long-Term Care Program.

Information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer the responsibility of CalPERS Long-Term Care Program or protected by the privacy rules under the Health Insurance Portability and Accountability Act.

I understand that I have the right to refuse to sign this Authorization, but if I do not sign the Authorization, CalPERS Long-Term Care Program will not be able to determine my eligibility for benefits.

_______________________________________________________________________________________ Signature of Claimant or *Legal Representative Date signed (Month, Day, Year)

*All signatures, other than that of the Claimant, must be identified and accompanied by appropriate documentation of

authority to represent the Claimant (for example: Durable Power of Attorney, Conservator, or Guardian)


THIRD PARTY AUTHORIZATION FORM for Use and Disclosures of Protected Health Information to an

Authorized Individual/Personal Representative

Instructions: In order to protect your privacy in compliance with state and federal laws, we cannot disclose information about you and your long-term care coverage to anyone, other than to you, unless you have authorized them in writing to receive such information as a personal representative to you. If you would like to authorize a third party to discuss your coverage on your behalf, please complete return this form via fax to 1-866-294-6967 (preferred) or mail to: CalPERS Long-Term Care Program, P.O. Box 64902, St. Paul, MN 55164.

I, ________________________________, Coverage ID Number ___________________, hereby authorize the use and disclosure of my protected health information for: coverage administration, billing information, and/or claims information, or as defined, or as limited to the following:

_______________________________________________________________________________________________ _______________________________________________________________________________________________ CalPERS Long-Term Care Program may release my protected health information as described above to the following individual(s):

By signing below, you are agreeing to the following statements: This form is for use and disclosures only; it does not authorize anyone other than me or my legal representative to make any changes to my: coverage, billing or demographic information. I understand that if the person or entity that receives my information is not covered by federal privacy regulations, my information may be re-disclosed by such person or entity, and will then no longer be protected. This authorization is valid until my coverage ends, unless a specific expiration dates or event is specified here: _______________. I understand that I may revoke this authorization in writing at any time. I am entitled to make a copy of, or request to receive a copy of this authorization. I understand that I am not required to sign this authorization and that payment or eligibility will not be conditioned upon my choice not to sign. I acknowledge by my signature below that I have read and understand this Authorization, it accurately reflects my wishes, and a photocopy, facsimile, or other electronic copy is as valid as the signed original. ________________________________________________________________________________________________

Signature of Claimant or *Legal Representative Date signed (Month, Day, Year) *If you are signing as a legal representative, describe the scope of your authority to act on their behalf and include a copy of the documentation of your legal authority.

_____________________________________________________________________________________________Printed Name of Authorized Individual Phone Number

_____________________________________________________________________________________________Street Address City State Zip Code

_____________________________________________________________________________________________Printed Name of Authorized Individual Phone Number

_____________________________________________________________________________________________Street Address City State Zip Code


DIRECT DEPOSIT FORM for Long-Term Care Claim Reimbursements

Instructions: Please complete and sign this form if you wish to use direct deposit for your long-term care benefit payments. You must also attach a copy of a Voided Check or Savings Account Withdrawal slip. If you are anyone other than the Claimant requesting a direct deposit, a completed Assignment of Benefits form and current W-9 are required for the direct deposit request to be completed. You may return the completed form via fax to 1-866-294-6967 (preferred) or mail to: CalPERS Long-Term Care Program, P.O. Box 64902, St. Paul, MN 55164.

Claimant Name: _______________________________________________________ Coverage ID Number: __________________________ Section I – Name for Direct Deposit Setup ______________________________________________________________________ Payee Name ______________________________________________________________________ Social Security # or Federal Tax ID # Section II – Direct Deposit Information Check off one: Initial Setup Account Change Enter the account where payment should be disbursed. The nine-digit transit number and account number is encoded at the bottom of your check. A copy of a VOIDED CHECK or SAVINGS ACCOUNT WITHDRAWAL SLIP must be attached to ensure the correct numbers are obtained. Please allow six weeks for setup of direct deposit. Account Type: Checking Savings

Bank Name Transit Number Account Number

Section III – Authorization I hereby authorize CalPERS Long-Term Care Program to initiate credit entries to the Bank indicated by the Transit Number on this form. If necessary, I also authorize debit entries and adjustments for any credit entries in error to my account indicated on this form. The authority is to remain in full force and effect until CalPERS Long-Term Care Program has received written notification from me of its termination in such time and in such manner as to afford CalPERS Long-Term Care Program and the Bank a reasonable opportunity to act on it. ________________________________________ ________________________________ Signature of Account Holder Date _______________________________________ ________________________________ Account Holder Name Account Holder Phone Number


ASSIGNMENT OF BENEFITS FORM

Instructions: Please complete and sign this form if you choose to assign your long-term care insurance benefits to a covered provider. In order to assign benefits, please be advised that we will only accept the Assignment of Benefits form. The provider must agree to this Assignment of Benefits and be willing to bill your long-term care insurance company directly for care/services provided to you. The Assignment of Benefits form is provided as a convenience to our policyholders and their care providers to assign benefits to the care provider, but not the rights under the policy. In addition, the covered provider must send us a completed W-9 form (required by the IRS). The Assignment of Benefits will not be in effect until CalPERS Long-Term Care Program has received the completed Assignment of Benefits form from you and the enclosed W-9 form from the covered provider. The Assignment of Benefits may be terminated in the future upon receipt of a written request stating you or the provider wishes to revoke the assignment. You may return the completed form via fax to 1-866-294-6967 (preferred) or mail to: CalPERS Long-Term Care Program, P.O. Box 64902, St. Paul, MN 55164.

Claimant Name: ________________________________________________ Coverage ID Number: ____________________________

I, _______________________________ , the Claimant or the guardian or other legal Representative of the Claimant (legal documentation of guardianship or other representative capacity, if appropriate, is attached), hereby authorize direct payment to ________________________________ (provider) of any long-term care benefits otherwise payable to or on behalf of the Claimant for the services provided at a rate not to exceed the Provider's regular charges. This Assignment of Benefits revokes any previous assignments authorized by the Claimant. It is understood that this Assignment of Benefits does not transfer any rights under the policy of insurance. It is agreed that payment to the Provider, pursuant to this Assignment of Benefits, by the plan administrator shall discharge CalPERS Long-Term Care Program of any and all obligation under the plan to the extent of such payments. It is understood by the undersigned that he/she is financially responsible for any charges not covered by this Assignment of Benefits. This Assignment of Benefits is valid for CalPERS Long-Term Care Program.

__________________________ __________ Service Provider Date Representative Signature

______________________________________ Printed Name of Service Provider Representative

__________________________ __________ Claimant/Legal Date Representative Signature

______________________________________ Printed Name of Claimant/Legal Representative*

*Financial Power of Attorney or other legal documentation is attached if signed by a Legal Representative

Provider’s Federal Tax ID Number/Social Security Number: _________________________________________ ____________________________________________________________________________________________ Name of Service Provider

____________________________________________________________________________________________ Street Address City State Zip Code

Form W-9(Rev. November 2017)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

▶ Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.

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1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ▶

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)• Form 1099-S (proceeds from real estate transactions)• Form 1099-K (merchant card and third party network transactions)• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)• Form 1099-C (canceled debt)• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

Cat. No. 10231X Form W-9 (Rev. 11-2017)

Documents

CalPERS Long-Term Care Program CLAIM INTAKE PACKET