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Relationship status
Is your partner applying for coverage?
Applicant
Name

First NameLast Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Height
Weight
Your gender at birth?
The gender you identify as today?
Note: We ask both questions because LTCI is fully underwritten and each carrier has individual guidelines for gender.
Have you used tobacco
Do you use marijuana?
Do you have a medical marijuana card?
Recently hospitalized overnight?
Details
List all medical conditions you have.
List all medications prescribed within the last 12 months.
List all surgeries performed OR recommended in the last 10 years.
Is there any parental history of cognitive impairment?
Who?
Have you been diagnosed with COVID?
Date of COVID diagnosis or positive test result.

MonthDayYear
Date
Treatment you received for COVID
Date of recovery from COVID

MonthDayYear
Date
Were you hospitalized while you had COVID?
Do you have any residual symptoms from COVID?
Contact Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Your Benefits

(Not all benefit options are available with all carriers. We will do our best to provide you with the best options available)
Products I'm interested in (select all that apply)
Monthly benefit
Custom monthly amount
Length of coverage
Inflation protection
Additional Information
Are you currently insured for LTC?
Have you previously looked into LTC?
Have you ever been previously declined for LTC?
How familiar are you with LTC?
How did you find us?
If you chose financial advisor, attorney, accountant, or insurance agent, please share their name.
Partner
Partner name

First NameLast Name
Partner email
example@example.com
Partner Phone Number
Format: (000) 000-0000.
Partner Date of Birth

MonthDayYear
Date
Partner Height
Partner Weight
Your gender at birth? (Partner)
The gender you identify as today? (Partner)
Note: We ask both questions because LTCI is fully underwritten and each carrier has individual guidelines for gender.
Have you used tobacco? (Partner)
Do you use marijuana?
Do you have a medical marijuana card?
Recently hospitalized overnight? (Partner)
Details
List all medical conditions you have (Partner).
List all medications prescribed within the last 12 months (Partner).
List all surgeries performed OR recommended in the last 10 years (Partner).
Is there any parental history of cognitive impairment? (Partner)
Who?
Have you been diagnosed with COVID? (Partner)
Date of COVID diagnosis or positive test result. (Partner)

MonthDayYear
Date
Treatment you received for COVID (Partner)
Date of recovery from COVID (Partner)

MonthDayYear
Date
Were you hospitalized while you had COVID? (Partner)
Do you have any residual symptoms from COVID? (Partner)
Partner Contact Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Your Benefits (Partner)

(Not all benefit options are available with all carriers. We will do our best to provide you with the best options available)
Products I'm interested in (Partner, select all that apply)
Monthly benefit (Partner)
Custom monthly amount (Partner)
Length of coverage (Partner)
Inflation protection (Partner)
Additional Information
Are you currently insured for LTC? (Partner)
Have you previously looked into LTC? (Partner)
Have you ever been previously declined for LTC? (Partner)
How familiar are you with LTC (Partner)
How did you find us? (Partner)
If you chose financial advisor, attorney, accountant, or insurance agent, please share their name.
Security Question
Should be Empty:

Applicant

Contact Information

Select Your Benefits

Additional Information

Partner

Partner Contact Information

Select Your Benefits (Partner)

Additional Information