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Questions with * are required. More detail = more accurate quotes.
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What is your opinion of LTC insurance?
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READY TO BUY - help me find best coverage/price
STILL LOOKING - need more info
NOT SURE IT'S RIGHT - just getting started
I HAVE COVERAGE - need review/update
Is your policy getting a premium increase?
Yes
No
Details about existing LTCI coverage, including: Company Name, Benefit Amounts, Premium:
Full Name:
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First Name
Last Name
Are you married? (Live with a Partner?)
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Yes
No
Are you requesting quotes for your spouse/partner too?
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Yes
No
Spouse/Partner Name:
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First Name
Last Name
E-mail:
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Phone Number:
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-
Area Code
Phone Number
Contact Preference:
E-Mail
Phone
I am comfortable relying on family/friends to provide at least part of my care:
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STRONGLY AGREE
AGREE
NEUTRAL
DISAGREE
STRONGLY DISAGREE
I am willing to co-insure a portion of my care expenses:
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STRONGLY AGREE
AGREE
NEUTRAL
DISAGREE
STRONGLY DISAGREE
Policy Benefit Preferences (if any):
Basic
Standard
Above Average
Benefit Amount
Total Benefit (length of coverage)
Inflation Coverage
(Enter spouse/partner health info after your info)
YOUR HEALTH INFORMATION:
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Current Age
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Month of Birth
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January
February
March
April
May
June
July
August
September
October
November
December
Height
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Feet & inches
Weight (@ doctor's office)
*
Pounds
Have you used tobacco of any kind in past year?
*
No
Yes
Type of tobacco:
*
Cigarettes
Cigar
Chew / Snuff
Select best option
How many / how often:
*
Do you have high blood pressure?
*
No
Yes
Is your blood pressure well controlled?
Yes, WITH medication
Yes, without medication
No
Select best option
List all blood pressure and/or heart medications. Include: Name, Dosage, Frequency, and Condition:
*
Do you have, or have you ever had any of the following conditions:
Cancer
Diabetes
Heart Attack
Stroke or TIA
CANCER - Date of Diagnosis:
-
Month
-
Day
Year
Date Picker Icon
CANCER - Type:
CANCER - Stage:
CANCER - Did it spread (Metastasis)?
No
Yes
CANCER - Describe the metastasis in detail:
CANCER - Treatment (Check all that apply):
Chemo
Radiation
Oral Prescription
CANCER - Treatment END date:
-
Month
-
Day
Year
Date Picker Icon
CANCER - Describe Treatment(s). List current prescriptions. Other treatments? Any recurrence?
DIABETES - Type (select one):
Type 2 oral medication only
Type 2 diet & exercise controlled
Type 2 WITH injected insulin
Type 1 NO insulin
Type 1 oral medication only
Type 1 WITH injected insulin
Choose best answer
DIABETES - Injected insulin units per day:
Numbers only. Decimals OK
DIABETES - Do you have any of the following?
A-fib
High blood pressure
Neuropathy
DIABETES - Last A1C reading:
Numbers only. Decimals OK
DIABETES - List medication(s), insulin type(s), including: Name, Dosage, Frequency; note if any type/dosage changed in last 6 months:
HEART ATTACK - Date (most recent, if multiple):
-
Month
-
Day
Year
Date Picker Icon
HEART ATTACK - More than one (1)?
No
Yes
HEART ATTACK - Describe type of treatment, surgery, by-pass, stent(s), etc. including dates (if multiple, note other dates/treatments):
*
HEART ATTACK - Do you have any activity limitations and/or complications?
No
Yes
HEART ATTACK - Describe limitations and/or complications:
STROKE/TIA - Date (most recent, if multiple):
-
Month
-
Day
Year
Date Picker Icon
STROKE/TIA - Describe any complications, limitations, and/or lingering effects:
STROKE/TIA - Have you had more than one (1) stroke and/or TIA?
No
Yes
STROKE/TIA - Describe event(s) & type(s) of treatment, surgery, medication, etc. including dates (if multiple, note other dates/treatments):
List prescription medications not already noted including: Name, Dosage, Frequency, Condition; note if any are new or changed in last 6 months:
Are you currently receiving physical or occupational therapy?
*
No
Yes
PHYSICAL THERAPY - Describe reason(s) for physical therapy or OT and prognosis:
Describe any OTHER medical condition(s) of significance:
SPOUSE/PARTNER HEALTH INFORMATION:
All data is securely encrypted
Following information is for:
First Name
Last Name
Spouse/Partner Age
*
Month of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Height
*
Feet & inches
Weight (@ doctor's office)
*
Pounds
Has your spouse used tobacco of any kind in past year?
*
No
Yes
Type of tobacco:
*
Cigarettes
Cigar
Chew / Snuff
Select best option
How many / how often:
*
Does your spouse have high blood pressure?
*
No
Yes
Is the blood pressure well controlled?
Yes, WITH medication
Yes, without medication
No
Select best option
List all blood pressure and/or heart medications. Include: Name, Dosage, Frequency, and Condition:
*
Does your spouse have, or have you ever had any of the following conditions:
Cancer
Diabetes
Heart Attack
Stroke or TIA
CANCER (SP) - Date of Diagnosis:
-
Month
-
Day
Year
Date Picker Icon
CANCER (SP) - Type:
CANCER (SP) - Stage:
CANCER (SP) - Did it spread (Metastasis)?
No
Yes
CANCER (SP) - Describe the metastasis in detail:
CANCER (SP) - Treatment (Check all that apply):
Chemo
Radiation
Oral Prescription
CANCER (SP) - Treatment END date:
-
Month
-
Day
Year
Date Picker Icon
CANCER (SP) - Describe Treatment(s). List current prescriptions. Other treatments? Any recurrence?
DIABETES (SP) - Type (select one):
Type 2 oral medication only
Type 2 diet & exercise controlled
Type 2 WITH injected insulin
Type 1 NO insulin
Type 1 oral medication only
Type 1 WITH injected insulin
Choose best answer
DIABETES (SP) - Injected insulin units per day:
Numbers only. Decimals OK
DIABETES (SP) - Does your spouse have any of the following?
A-fib
High blood pressure
Neuropathy
DIABETES (SP) - Last A1C reading:
Numbers only. Decimals OK
DIABETES (SP) - List medication(s), insulin type(s), including: Name, Dosage, Frequency; note if any type/dosage changed in last 6 months:
HEART ATTACK (SP) - Date (most recent, if multiple):
*
-
Month
-
Day
Year
Date Picker Icon
HEART ATTACK (SP) - More than one (1)?
No
Yes
HEART ATTACK (SP) - Describe type of treatment, surgery, by-pass, stent(s), etc. including dates (if multiple, note other dates/treatments):
HEART ATTACK (SP) - Any activity limitations and/or complications?
No
Yes
HEART ATTACK (SP) - Describe limitations and/or complications:
STROKE/TIA (SP) - Date (most recent, if multiple):
-
Month
-
Day
Year
Date Picker Icon
STROKE/TIA (SP) - Describe any complications, limitations, and/or lingering effects:
STROKE/TIA (SP) - Has your spouse had more than one (1) stroke and/or TIA?
No
Yes
STROKE/TIA (SP) - Describe event(s) & type(s) of treatment, surgery, medication, etc. including dates (if multiple, note other dates/treatments):
List (SP) prescription medications not already noted including: Name, Dosage, Frequency, Condition; note if any are new or changed in last 6 months:
Is your spouse currently receiving physical or occupational therapy?
*
No
Yes
PHYSICAL THERAPY (SP) - Describe reason(s) for physical therapy or OT and prognosis:
Describe any OTHER (SP) medical condition(s) of significance:
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