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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