Long Term Care Request

The underwriting of Long Term Care Insurance differs from that of other products (such as life insurance) in that one must consider many unique factors, which might not seem important for another type of insurance . Our mission is to provide the highest quality service to you and your clients. Good health pre-qualifying allows us to help you place the right policy for your clients quickly and accurately.






    Broker Information

    Broker Name*
    Address
    City
    State
    Zip
    Phone*
    Fax
    Email*

    Client #1

    Client #1 Name*
    Date of Birth*
    Gender*
    MaleFemale
    State
    Height
    feet
    inches
    Weight
    pounds
    Married
    YesNo

    1. Have you used tobacco products in the last 12 months?
    YesNo

    2. Within the last 5 years, have you received medical advice, diagnosis, treatment, or consulted with a medical professional for:

    A. Circulatory disorders (includes high blood pressure)
    YesNo

    B. Endocrine and pituitary disorders
    YesNo

    C. Cancers
    YesNo

    D. Genital urinary disorders
    YesNo

    E. Gastrointestinal disorders
    YesNo

    F. Neurological disorders
    YesNo

    G. Blood disorders
    YesNo

    H. Musculoskeletal disorders
    YesNo

    I. Respiratory disorders
    YesNo

    J. Eye and ear disorders
    YesNo

    K. Substance abuse
    YesNo

    3. Have you had any surgery recommended or anticipated?
    YesNo

    4. Are you currently receiving physical therapy?
    YesNo

    5. Do you currently use any assistive or mechanical devices?
    YesNo

    6. Have you ever received home health care or been confined to a
    nursing home or rehabilitation facility?
    YesNo

    7. Do you require human assistance or supervision in performing any
    of your activities of daily living?
    YesNo

    8. Have you had a complete physical exam within the past 18 months?
    YesNo

    List any prescription medication taken and dosage:
    Please give details to questions 2 through 7, if Yes is checked:
    ? #
    Diagnosis
    Diagnosis Date
    Treatment
    Relationship between Client 1 and Client 2:
    State the Illustration is for:

    Client #2 (only if joint)

    Client #2 Name
    Date of Birth
    Gender
    MaleFemale
    State
    Height
    feet
    inches
    Weight
    pounds
    1. Have you used tobacco products in the last 12 months?
    YesNo

    2. Within the last 5 years, have you received medical advice, diagnosis, treatment, or consulted with a medical professional for:

    A. Circulatory disorders (includes high blood pressure)
    YesNo

    B. Endocrine and pituitary disorders
    YesNo

    C. Cancers
    YesNo

    D. Genital urinary disorders
    YesNo

    E. Gastrointestinal disorders
    YesNo

    F. Neurological disorders
    YesNo

    G. Blood disorders
    YesNo

    H. Musculoskeletal disorders
    YesNo

    I. Respiratory disorders
    YesNo

    J. Eye and ear disorders
    YesNo

    K. Substance abuse
    YesNo

    3. Have you had any surgery recommended or anticipated?
    YesNo

    4. Are you currently receiving physical therapy?
    YesNo

    5. Do you currently use any assistive or mechanical devices?
    YesNo

    6. Have you ever received home health care or been confined to a
    nursing home or rehabilitation facility?
    YesNo

    7. Do you require human assistance or supervision in performing any
    of your activities of daily living?
    YesNo

    8. Have you had a complete physical exam within the past 18 months?
    YesNo

    List any prescription medication taken and dosage:
    Please give details to questions 2 through 7, if Yes is checked:
    ? #
    Diagnosis
    Diagnosis Date
    Treatment
    Relationship between Client 1 and Client 2:
    State the Illustration is for:

    Benefit Section

    Available options may vary by carrier and state

    Type of Coverage
    IndividualJointLinked Benefit (Life + LTC)
    Max Benefit Amount
    per DayMonth

    Elimination Period:

    Benefit Period:

    Inflation Protection

    Premium Mode

    Pay Options

    First Carrier Preference

    Second Carrier Preference

    Additional Riders/Comments/Special Requests

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