Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current state of residence
*
ex: IL
Name of Insurance Carrier
*
Do you have an active agent (who sold you your LTCI policy)?
*
Yes
No
Are you actively receiving care?
*
Yes
No
If you're actively receiving care, what is the start date of care?
*
-
Month
-
Day
Year
Date
Is Medicaid paying for any services you are receiving?
*
Yes
No
Do you need assistance with at least 2 of the 6 Activities of Daily Living (ADLs)?
*
Please Select
Yes
No
The 6 Activities of Daily Living (ADLs) are: eating (you can't feed yourself), bathing, dressing, transferring, toileting, and continence.
Have you already filed a claim?
*
Yes
No
On what date did you file your claim?
*
-
Month
-
Day
Year
Date
Was your claim denied?
*
Yes
No
Briefly tell us why your claim was denied?
*
How did you hear about us?
*
Please Select
Accountant / Attorney / Financial Advisor
Insurance Agent/Broker
Friend / Family
Google/Bing/Online search
Nextdoor
WGN Radio
Price of Business Radio Show
Terry Savage
Other
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