Your name:
Email address:
Phone:
Date Of Birth:
Best Time To Call:
Height :
Weight:

Actively at Work?

Yes
No
Retired

Active Driver?

Yes
No

Are You A Smoker?

Yes
No

Any Pre-existing Health conditions?

I don't know
Yes
No

Any Illnesses, hospitalization or surgery in last 3-5 years?

Yes
No

 

                 Medications, Dosages & Reason

 

Do you have any children? Yes No

Would they be available to provide care? Yes No

Objective for Inquiring about Long Term Care Insurance - Please check any that apply:

Not to become a burden to spouse
Not to become a burden to children
Afford quality health care
Protect assets and income
Insure asset transfer
Avoid going on Medicaid

                                         Any Comments?