Asset-Based LTC Quote Request
Prior our introductory conversation, we ask that you complete the questions below. These questions will help you identify goals and help us put together an accurate proposal for you. Plan on about 10 – 15 minutes to complete them. Once we receive these we will reach out with scheduling options. This is a secure form. Info is not publicly available.
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Spouse, if married
First Name
Last Name
Spouse Email
example@example.com
Spouse Date of Birth
-
Month
-
Day
Year
Date
State
Street Address
Street Address Line 2
City
Postal / Zip Code
If you needed $250,000 to pay for a Long-Term Care claim which asset that you currently own would you liquidate first?
For example, if you would use a portion of your 401k, populate that field below with the current account balance.
Checking / Savings
Stocks / Bonds
IRA / 401K
Non-Qualified Annuity
Other
Pre-Screening PART A - Client & Spouse (if applicable)
Health Statement - Part A (Check those that apply)
Client
Spouse (if applicable)
Within the past two years have you been confined
to a nursing home, assisted living center, received
or been advised to receive hospice care, been
advised that you have a terminal illness or need
assistance with: bathing, eating, dressing,
toileting, transferring into and out of bed, chair, or
wheelchair and/or maintain continence?
Are you currently hospitalized, bedridden or use
medical devices such as: wheelchair, walker, dialysis
machine, oxygen equipment, respirator, stair lift, chair
lift, motorized scooter or taking medications Aricept,Exelon, Reminyl or Namenda?
Have you ever been diagnosed by a member of the
medical profession as having AIDS, HIV, or ARC
disorders, or tested positive for antibodies for the AIDS
virus?
If under the age of 65, is there any reason you are not
physically and mentally capable of active employment
or are you currently receiving or have received within
the past five years social security disability income
benefits?
Have you ever been diagnosed, treated, tested positive
for, or been given professional medical advice for:
Alzheimer’s disease, dementia, memory loss, multiple
sclerosis, muscular dystrophy, ALS (Lou Gehrig’s
disease) Parkinson’s disease, down syndrome, organ
transplant (other than kidney) or active cancer?
Are you a smoker?
Pre-Screening PART B - Client Only
Client Name
Height
Weight
In the past 5 years, is there a history of:
Diabetes
Depression
Uncontrolled High Blood Pressure
Cancer
Chronic Obstructive Pulmonary Disease (COPD)
Leukemia
Heart Disease
Congestive Heart Failsure
Organ Failure / Disease
Heart Attack
Stroke
Cardiomyopathy
Amyotrophic Lateral Sclerosis (ALS)
Chronic Obstructive Lung Disease (COLD)
Alcohol / Drug Abuse
IF ABOVE CHECKED PLEASE PROVIDE DETAILS ON NOTES SECTION
Other not listed above
Client Prescription List
Details
Spouse Pre-Screening (if applicable)
Spouse Name
Height
Weight
In the past 5 years, is there a history of:
Diabetes
Depression
Uncontrolled High Blood Pressure
Cancer
Chronic Obstructive Pulmonary Disease (COPD)
Leukemia
Heart Disease
Congestive Heart Failsure
Organ Failure / Disease
Heart Attack
Stroke
Cardiomyopathy
Amyotrophic Lateral Sclerosis (ALS)
Chronic Obstructive Lung Disease (COLD)
Alcohol / Drug Abuse
IF ABOVE CHECKED PLEASE PROVIDE DETAILS ON NOTES SECTION
Other not listed above
Spouse Prescription List (if applicable)
Spouse Prescription Details
Income
Monthly Income Estimate
Client Income
Spouse
Social Security
Gross Wages
Pensions
Other
Total
Expenses
Please estimate your monthly expenses below:
NOTES
If there's anything else you'd like to note, please address here.
Submit
Should be Empty: