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Long Term Care Insurance Questionnaire

If you do not have a local insurance professional who is knowledgeable about long-term care insurance and are interested in obtaining a Long-Term Care insurance policy, please select "Yes" below and fill out the questionnaire. This will allow us to see what we can offer you, as well as save precious time! You will receive a response within 24-48 hours from the time of your post.

No, I just want to send a question or comment.
Yes! I want to fill out the questionnaire.

Your Name*

FirstLast

Your Phone Number

Your Email*

Your Birthdate*

MM

DD

YYYY

Your Height and Weight*

Any pending surgery?*

Yes
No

Please describe your pending surgery*

Any surgery in the past 12 months?*

Yes
No

Please describe your surgery*

Are you currently receiving physical therapy?*

Yes
No

Please describe your physical therapy*

Are you taking any prescription medications?*

Yes
No

Please describe your medications*

Include name of drug(s), dosage, frequency, and reason for taking it.

Any change in how your medications are prescribed in the last 6 months?*

Yes
No

Please describe your changes in medications*

Family Longevity: Do people in your family live to be age 90+?*

Yes
No

Any history of Alzheimer's in your family?*

Yes
No

Do you have any other long term care insurance coverage?*

Yes
No

Please describe your current long term care coverage*

Spouse / Partner Information*

If you currently have a spouse / partner, select "Yes" and fill out the spouse / partner questionnaire that appears.

Yes, I currently have a spouse / partner.
No, I do not have a spouse / partner.

Spouse / Partner Questionnaire

Your Spouse / Partner's Name*

FirstLast

Your Spouse / Partner's Birthdate*

MM

DD

YYYY

Your Spouse / Partner's Height and Weight*

Any pending surgery for your spouse / partner?*

Yes
No

Please describe your spouse / partner's pending surgery*

Any surgery in the past 12 months for your spouse / partner?*

Yes
No

Please describe your spouse / partner's surgery*

Is your spouse / partner currently receiving physical therapy?*

Yes
No

Please describe your spouse / partner's physical therapy*

Is your spouse / partner taking any prescription medications?*

Yes
No

Please describe your spouse / partner's medications*

Include name of drug(s), dosage, frequency, and reason for taking it.

Any change in how your spouse / partner's medications are prescribed in the last 6 months?*

Yes
No

Please describe your spouse / partner's changes in medications*

Family Longevity: Do people in your spouse / partner's family live to be age 90+?*

Yes
No

Any history of Alzheimer's in your spouse / partner's family?*

Yes
No

Does your spouse / partner have any other long term care insurance coverage?*

Yes
No

Please describe your spouse / partner's current long term care coverage*

Where do you live now and do you intend to retire there?*

If no, where do you think you might retire?

Questions or Comments*

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