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LONG-TERM CARE INSURANCE QUOTE

We would like to provide you with a free, no-obligation Long-Term Care insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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Personal Information
Insured's Name (First, Last): Date of Birth:
Sex: Tobacco Use:   US Citizen / Green Card:  
Male   Female Yes   No Yes   No
Marital Status: Height: Weight:
Married Single ft./in. lbs.
Physical Address:
City:   State:   Zip:
Is the mailing address the same as the physical address? Y N
Mailing Address:
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:

How Did You Hear About Us?
Please check all that apply:
Search Engine Social Network Advertisement Family or Friend
Forum/Blog Co-Worker Other:

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.

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One of our representatives will respond to your submission as soon as possible.

   


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