Relationship status
*
Please Select
Single
Domestic Partner
Married
Is your partner applying for coverage?
*
Yes (after completing the form for yourself, continue on for your partner)
No
Applicant
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Height
*
Weight
*
Your gender at birth?
*
Male
Female
The gender you identify as today?
*
Please Select
Male
Female
Please call me to discuss
Note: We ask both questions because LTCI is fully underwritten and each carrier has individual guidelines for gender.
Have you used tobacco
*
Yes, in the last 5 years
No
Recently hospitalized overnight?
*
Yes, in the last 5 years
No
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?
*
Yes
No
Who?
*
Have you been diagnosed with COVID?
*
Yes
No
Date of COVID diagnosis or positive test result.
*
-
Month
-
Day
Year
Date
Treatment you received for COVID
*
Date of recovery from COVID
*
-
Month
-
Day
Year
Date
Were you hospitalized while you had COVID?
*
Yes
No
Do you have any residual symptoms from COVID?
*
Yes
No
Contact Information
Address
*
Street Address
Street Address Line 2
City
State / 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)
*
Stand-Alone
Hybrid / Life LTC
Hybrid / Annuity LTC
Monthly benefit
Please Select
Custom Amount
$3,000
$3,500
$4,000
$4,500
$5,000
$5,500
$6,000
$6,500
$7,000
$7,500
$8,000
$8,500
$9,000
$9,500
$10,000
More than $10,000
Custom monthly amount
Length of coverage
Please Select
2 years
3 years
4 years
5 years
6 years
10 years
Lifetime (unlimited)
Inflation protection
Please Select
No inflation protection (no growth - benefit stays flat over time)
Inflation protection (benefits grow over time)
Additional Information
Are you currently insured for LTC?
Yes
No
Have you previously looked into LTC?
Yes
No
Have you ever been previously declined for LTC?
Yes
No
How familiar are you with LTC?
Please Select
Novice
Intermediate
Expert
How did you find us?
Please Select
Accountant/CPA
Attorney
Financial Advisor
Insurance Agent/Broker
A client of ours
Google/Bing/Online search
Price of Business Radio Show
Terry Savage
Other
If you chose financial advisor, attorney, accountant, or insurance agent, please share their name.
Partner
Partner email
*
example@example.com
Partner Phone Number
*
Partner Date of Birth
*
-
Month
-
Day
Year
Date
Partner Height
*
Partner Weight
*
Your gender at birth? (Partner)
*
Male
Female
The gender you identify as today? (Partner)
*
Please Select
Male
Female
Please call me to discuss
Note: We ask both questions because LTCI is fully underwritten and each carrier has individual guidelines for gender.
Have you used tobacco? (Partner)
*
Yes, in the last 5 years
No
Recently hospitalized overnight? (Partner)
*
Yes, in the last 5 years
No
2 Recently hospitalized overnight? (Partner)
*
Yes, in the last 5 years
No
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)
*
Yes
No
Who?
*
Have you been diagnosed with COVID? (Partner)
*
Yes
No
2 Have you been diagnosed with COVID? (Partner)
*
Yes
No
Date of COVID diagnosis or positive test result. (Partner)
*
-
Month
-
Day
Year
Date
Treatment you received for COVID (Partner)
*
Date of recovery from COVID (Partner)
*
-
Month
-
Day
Year
Date
Were you hospitalized while you had COVID? (Partner)
*
Yes
No
Do you have any residual symptoms from COVID? (Partner)
*
Yes
No
Partner Contact Information
Address
*
Street Address
Street Address Line 2
City
State / 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)
*
Stand-Alone
Hybrid / Life LTC
Hybrid / Annuity LTC
Monthly benefit (Partner)
Please Select
Custom Amount
$3,000
$3,500
$4,000
$4,500
$5,000
$5,500
$6,000
$6,500
$7,000
$7,500
$8,000
$8,500
$9,000
$9,500
$10,000
More than $10,000
Custom monthly amount (Partner)
Length of coverage (Partner)
Please Select
2 years
3 years
4 years
5 years
6 years
10 years
Lifetime (unlimited)
Inflation protection (Partner)
Please Select
No inflation protection (no growth - benefit stays flat over time)
Inflation protection (benefits grow over time)
Additional Information
Are you currently insured for LTC? (Partner)
Yes
No
Have you previously looked into LTC? (Partner)
Yes
No
Have you ever been previously declined for LTC? (Partner)
Yes
No
How familiar are you with LTC (Partner)
Please Select
Novice
Intermediate
Expert
How did you find us? (Partner)
Please Select
Accountant/CPA
Attorney
Financial Advisor
Insurance Agent/Broker
A client of ours
Google/Bing/Online search
Price of Business Radio Show
Terry Savage
Other
If you chose financial advisor, attorney, accountant, or insurance agent, please share their name.
Security Question
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