Contact Information | |
| How did you hear about us? | |
| What Station, Paper, or Friend or Family Referred you? | |
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| Last Name: | |
| First Name: | |
| Joint Application: | Yes (Check) |
| Spouse's First Name: | |
| Address: | |
| City: | |
| State: | |
| ZIP Code: | |
| Home Phone: | |
| Work or Cell Phone: | |
| Best Time to Call: | |
| Email: | |
| OK - Add Email to Newsletter: | Yes (check) |
| Date of Birth: | |
| Height: | |
| Weight: | |
| Spouse's Date of Birth: | |
| Spouse's Height: | |
| Spouse's Weight: | |
Financial Questions | |
| Do you have Assets between: | |
| Are you currently working? | Yes (check) |
Medical Questions |
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| Do you currently have LTCI? | Yes (check) |
| Have you been previously declined or rated for LTCI? | Yes (check) |
| Do you currently need assistance now? | Yes (check) |
Do you use any of the following:
Cane, Crutches, Brace, Hospital Bed, Lift Chair, Walker, Wheelchair, Oxygen, Kindney Dialysis | Yes (check) |
| Do you use Tobacco in any form? | Yes (check) |
| Are you receiving or ever received worker's compensation or disability? | Yes (check) |
| Any Physical limitations or Restrictions? | Yes (check) |
| Do you have High Blood Pressure? | Yes (check) |
| Do you have any pending surgeries, test, procedures that have been recommended but not performed? | Yes (check) |
| Have you used a nursing home or home health care services in last 5 Years? | Yes (check) |
| Any memory loss, forgetfulness or confusion? | Yes (check) |
List any condition you have now or in last 5 years:
Arthritis, Cancer, Osteoporosis, Glaucoma, Fibromyalgia, Diabetes, Prostate Condition, Blindness, Back or Joint Surgery, Depression or Anxiety, COPD, Bipolar Disorder, CVA, Dizziness, Emphysema, Nervous Disorder, TIA, Falls, Respiratory Problems Heart Disease, Vision Problems, Epilepsy, Sleep Apnea, Aneurysm, Macular Degeneration, Seizures | |
| List all Medications Taken in last year? | |
| Anything else about your health we should know? | |
| Approximate Date Last seen by Doctor? | |
| Monthly Benefit: | |
| Elimination Period: | |
| Years of Benefits: | |
| Inflation Protection: | |
| Nonforfeiture Benefit: | Yes (check) |
| Restoration of Benefits: | Yes (check) |
| Payout Options: | |
| Option Riders (depends on product): | |
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