Hawaii Life & Disability Insurance Guaranty Association

Forms

Effective April 1, 2021, the Guaranty Association will provide policy and claims services to Hawaii residents owning a Penn Treaty Long Term Care Policy. Click here to view the notice sent to policyholders on February 15, 2021.

Please select a form below for Penn Treaty Network America Insurance Company (PTNA).

• ACH (Automatic Draft) Authorization Form
• Address Change Form
• Assignment of Benefits Form
• Assisted Living Claim Packet
• Authorization to Release Information Form
• Cancellation Request Form
• Estate Affidavit Form
• Home Health Care Claim Packet
• Monthly Care Certification Form
• Nursing Home Claim Packet
• Physician Statement (Home Health Care)
• Physician Statement (Long Term Care)
• Weekly Care Certification Form

Please contact us by mail, email*** or telephone if you are looking for information that has not been provided in the notice or on our website so we may assist you.

Hawaii Life & Disability Insurance Guaranty Association
1003 Bishop Street Suite 2030 Honolulu, HI 96813
Email address: PennTreatyAloha@hilifega.org
Phone Number: 808-744-4919

***Please ensure to send your personal information securely if you are submitting it using your email address. Contact us by telephone if you need assistance in sending your personal information.***