Disclaimer

I understand that this does not constitute an actual "live" online quote, but is rather a submission of information to Head Insurance Group so that they may put together an insurance proposal (quote) for the above titled risk. There is no obligation on my part to purchase this insurance, and I understand that this online submission does not constitute a statement or contract for insurance.  I have read and agree with the above disclaimer.   (Box must be checked before request can be sent)

General Information
Name:
Address:
City:	State:   Zip:
Day Phone:	Night Phone:
Email Address:	Soc. Sec.#:
Date of Birth (mm/dd/yy):	Age:       Sex: M F
Height:	ft./in.       Weight: lbs.
Marital Status:	Married Single   If married, will spouse also apply for coverage? Y N   NOTE: If "YES", your spouse will need to complete a seperate form.

Current/Previous Insurance Information
Do you currently have another Long-Term Care insurance policy, rider or certificate (including health care service contract or health maintenance organization contract)?	Y   N
Did you previously have another Long-Term Care insurance policy, rider or certificate in force during the last 12 months? If so, when did it lapse (mm/dd/yy):	Y   N
Are you covered by a state assistance program (Medicaid)?	Y   N
Do you intend to replace any of your medical or health insurance coverage with this policy, rider or certificate?	Y   N
Are you now receiving long-term care or disability benefits?	Y   N
Have you ever been denied coverage for medical insurance, disability insurance, long-term care insurance, nursing home insurance, or life insurance? If "Yes", please explain below:	Y   N

Activities Information
Have you been confined to a hospital in the last 12 months?	Y   N
Has a physician recommended in the past 24 months that you be hospitalized or confined to a nursing facility, or that you have a surgical procedure?	Y   N
Have you consulted with a physician in the last 12 months for loss of appetite, falling, unstable gait, bladder or bowel control, dizziness or vision problems, or weight loss of 10 pounds or more?	Y   N
Do you need the help or supervision of another individual to perform your everyday living activities such as walking, dressing, eating, taking medications or tending to personal hygiene?	Y   N
Do you need the help or supervision of another individual to perform the independent activities of daily living such as handling your finances, doing laundry, shopping or using the telephone?	Y   N
Do you use any assistive devices such as a walker, wheelchair, crutches, cane, grab bars or any prescribed medical device or applicance? If "Yes", please explain below:	Y   N

Medical Information
If you answer "Yes" to any of the questions below, please use the text box at the end of this section to explain your answer.
In the past 5 years have you ever had, been told by a physician you had, or been treated for:
--osteoarthritis, osteoporosis, amputation, bone or joint disease, rheumatoid arthritis, or spinal stenosis?	Y   N
--internal cancer, tumor, leukemia, lymphoma, or Hodgkins disease?	Y   N
--disease of the kidney, stomach, liver, pancreas, or small or large intestine; or cirrhosis?	Y   N
--diabetes or thyroid disease?	Y   N
--disease of the lungs or respiratory system, emphysema, asthma, or shortness of breath?	Y   N
--disease of the heart or circulatory system, heart attack, high blood pressure or angina?	Y   N
--psychological, psychiatric or mental disorders, anxiety or depression?	Y   N
--neurological disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, stroke/TIA, paralysis, convulsions, epilepsy, seizures or muscular dystrophy?	Y   N
Have you been treated or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or have you tested positive for the HIV virus (as indicated by the results of the ELISA-ELISA Western blot test series)?	Y   N
Have you received medical advice, treatment or counseling relating to alcohol or drug abuse?	Y   N
If you answered "Yes" to any question in this section, please explain your answer(s) below:

Medication Information

Please list below any prescription medications that you are currently taking:

Additional Information
Do you have a valid drivers license and drive at least twice per week?	Y   N
Are you employed outside of the home or do you participate in any volunteer activities or organizations at least 8 hours per week?	Y   N
Have you used tobacco products within the past 12 months?	Y   N

Additional Comments

Please give any additional comments you feel appropriate for this quotation.

Before Submitting Your Information...

I understand that all of the above information MUST BE COMPLETED in order to obtain an Insurance Quote. Head Insurance Group will be unable to provide me an insurance quote if any fields above are left blank or are partially filled in. PLEASE re-check your information before submitting!  I have read and agree with the above disclaimer.   (Box must be checked before request can be sent)

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.