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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