Last updated: November 21st, 2019
Name & Address
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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California
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Connecticut
Delaware
District of Columbia
Florida
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Idaho
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Kansas
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Maine
Maryland
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Michigan
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New Hampshire
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New Mexico
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North Carolina
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Northern Mariana Islands
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Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
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U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
Email Address
Age
Date of Birth
MM slash DD slash YYYY
Height
Weight
Marital Status
Single
Married
Divorcced
Widow
Other
Medical Condition(s)
Have you had Covid-19?
Yes
No
If you have recovered from Covid-19, are you still having residual issues?
Yes
No
Medical Condition(s)/Chronic Conditions/Diagnosis - list ALL conditions treated or diagnosed.
Condition
Date of Diagnosis
List Prescription Medicines taken within the past 12 months.
Medications
Medications
Dosage / Frequency
Disorder/Disease
Date of Diagnosis
Are you currently in PT? Or have you recently completed a PT program? Please provide details and dates.
Any diagnosis of an immune system disease /disorder? Higher or elevated levels for blood , kidney or edocrine? Provide Details.
Have you had a physical within the last 2 years?
Yes
No
Any unresolved or unstable conditions?
Yes
No
Handicap Parking Permit?
Yes
No
Treatment for Depression?
Yes
No
Use of CPAP Machine?
Yes
No
Stroke/TIA’s?
Yes
No
Receiving Social Security Disability or Workmen’s Compensation?
Yes
No
Any surgeries recommended or pending?
Yes
No
Diagnosis of Osteopenia?
Yes
No
Diagnosis of Osteoporosis?
Yes
No
Bone Density Score (Required for Osteoporosis)
Diabetic/A1C Score
2 or more concussions?
Yes
No
Do you have a family history of Alzheimer’s, dementia or Parkinsons
Yes
No
Tobacco Use?
Yes
No
Lifestyle Goals
Is LTC Insurance something you and your spouse have looked into before or is this new to you?
New
Considered Previously
Declined
If declined please provide details.
What are you hoping LTC Insurance could accomplish for you? Why now?
What, if any, issues are you concerned about? Protecting your assets? Burdening your loved ones or having quality care when you really need it?
Because of variance in regional cost of care, what State, region or country do you think you might retire? Is International retirement planned?
Our objective is to provide the most value at the lowest premiums that fit your definition of the lifestyle you aspire to. What, if any, specific issues, parameters or guidance do we need to be aware of?
Do you have a residence outside of this State? Carriers offer policies and options that vary in price between the States. We may consider dual residence or use alternative address in our evaluation. If you have an out of state property, please advise on physical street address.
The government has many incentives to help finance LTC insurance. These include 1035 tax free exchanges from a life insurance or annuity cash value which can be used to purchase LTC. Do you have whole life with cash value or annuities that you would like to use to finance your policy premium? We can also consider using funding from an IRA account (not tax free). To optimize Federal and State Tax Incentives, please check off all that apply to you:
Business Owner
Sole Proprietor
C Corp
S Corp
Partnership / LLC
Itemize Medical Expenses
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