LTC: Beginning Your Quote

First Name

Last Name:

Gender:  male female

Date Of Birth:

Marital Status : Married Unmarried 

Height/Weight: /

Spouse Name:

Spouse Last Name:

Age:

Date Of Birth:

Smoker? : YesNo

Is the spouse applying for coverage now?: YesNo

If no Spouse is named above, is the client currently married? : YesNo

If yes after you finish filling this form please provide the information in another form for the spouse.

Please check all that apply

 Does the applicant smoke or use another form of tobacco?

 Does the applicant live in some form of residential retirement community?

 Does the applicant work outside his/her home at least 10 hours per week?

 Does the applicant have special driving or parking needs?

Does Applicant need assistance with any of the following?

 Paying bills Balancing a checkbook Housekeeping or meal preparation Shopping Managing medications

The applicant currently lives:

 Alone With spouse With other family members Other

Medical History

This information will help us find you the best health insurance rates and will be verified by your agent.
Please check all that apply:

 This policy is intended to replace any other medical or health insurance coverage or the applicant has another long term care insurance policy or certificate in force. This includes a health care service contract or a health care maintenance organization contract
 The applicant has been denied long term care coverage
 The applicant has been advised by a member of the medical profession to have surgery (including an organ transplant) that has not been performed
 The applicant has been confined to a hospital or nursing home, received services of a home health care agency or adult day care in the past 12 months
 The applicant is receiving ongoing medical treatment (excluding regular pap smears, voluntary check-ups, etc.)
 The applicant needs assistance or supervision by another individual for dressing, eating, personal hygiene (bathing or toilet), walking or transferring to and from a bed or chair
 The applicant needs assistance or supervision by another individual for dressing, eating, personal hygiene (bathing or toilet), walking or transferring to and from a bed or chair
 The applicant uses a cane, crutches, catheter, oxygen equipment, respirator, dialysis machine, walker, wheelchair, quad or tripod cane, motorized scooter or chair lift
 The applicant is covered under a state Medicaid program, receiving disability, Social Security disability, or workers compensation benefits

Medical Conditions

Have you been diagnosed with any of the following conditions?

Please check all that apply.
 HIV/AIDS Heart attack Stroke Diabetes High blood pressure Depression requiring hospitalization Cancer Asthma Kidney failure Alzheimer's disease, dementia or other senility disorder Seizure disorder Congestive heart failure Cirrhosis of the liver Systemic Lupus Erythematosus Transient Ischemic Attack (TIA) Eye disorder (Glaucoma, Cataracts, etc.) Skin disorder Psychosis or Severe neurosis Cerebral aneurysm Ulcerative Colitis or other digestive disorder Arthritis or joint replacement Cardiomyopathy Lung disease (Emphysema, Chronic Bronchitis etc.) Hepatitis Alcoholism or drug abuse Other major illness

Just a few more questions...

Current Work Status:

Assets:

Medications - Long Term Care Insurance

This section will allow you to enter as many medications as needed for each member of your family. Please add all medications and click Continue after you have entered at least one medication.

Listed Medications: