FORM 1099-LTC ISSUER RECONCILIATION CHECKLIST
Tax Year:
Policy/Contract Number:

1. ENTITY IDENTIFICATION
[ ] Policyholder Name:
[ ] Policyholder TIN (Validated):
[ ] Is Policyholder an Individual? (If No, STOP - reporting not required)
[ ] Insured Name:
[ ] Insured TIN (Validated):
[ ] Are Policyholder and Insured the same person? (Determines Copy C necessity)

2. GROSS PAYMENT AGGREGATION
[ ] Total payments made directly to Policyholder: $
[ ] Total payments made directly to Insured (if different): $
[ ] Total payments made directly to Third-Party Providers (Nursing homes, caretakers): $
[ ] Total Gross Long-Term Care Benefits (Sum for Box 1): $
[ ] Total Accelerated Death Benefits / Viatical Payments (Sum for Box 2): $

3. PAYMENT BASIS & OPTIONAL INDICATORS
[ ] Box 3 Indicator check: ( ) Per Diem  ( ) Reimbursed Amount
[ ] (Optional) Box 4: Is this a Qualified Contract? (Y/N)
[ ] (Optional) Box 5: Is Insured Chronically/Terminally Ill? (Y/N) Date:

4. FURNISHING VERIFICATION
[ ] Copy B generated for Policyholder
[ ] Copy C generated for Insured (if applicable)
[ ] TINs truncated on physical/PDF payee statements
[ ] Full TINs preserved for IRS electronic transmission file

Reviewed By: ___________________ Date: ______________