Long Term Care Questionnaire

Long Term Care Questionnaire
2213 E Grand River Ave Suite B Lansing, MI 48912 844-705-3289

Ryan Heintz - Account Executive Edge Insurance Group
CLIENT INFORMATION
CLIENT NAME
Gender
Date of Birth
State of Residence
Tobacco User
Type of Tobacco
Height / Weight
Phone Number
Format: (000) 000-0000.
Marital Status
SPOUSE'S NAME
Gender
Spouse Date of Birth
State of Residence
Tobacco User
Type of Tobacco
Height / Weight
Phone Number
Format: (000) 000-0000.
MEDICATIONS
Please list all current medications along with their purpose, dosage, length of usage, and number of times per day
HOSPITALIZATIONS
Please list all hospitalizations in the past 5 years, including dates and reason

MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MEDICAL HISTORY (specific to underwriting for long term care)
Long Term Care Supplemental Questionnaire
1. Do you currently use any of the following:
2. Do you currently need assistance with any of the following:
3. Have you ever been treated for any of the following conditions:
4. Have you been diagnosed with any of the following conditions?
COPD Asthma Bronchitis
Date of diagnosis Hospitalization(s)

MonthDayYear
Date
Treatment
Crohn's Colitis Diverticulitis
Date of Last Flare-Up

MonthDayYear
Date
Date of Diagnosis Treatment

MonthDayYear
Date
Osteoporosis
If Yes, Date of Diagnosis Treatment

MonthDayYear
Date
Most Recent Bone Density Score
Arthritis
If Yes, What Type?
Date of diagnosis? Restrictions?

MonthDayYear
Date
Joint Replacements? Injections?
Fibromyalgia
Date of diagnosis and list any limitations

MonthDayYear
Date
Treatment(s)
Lupus
If Yes, What Type? SLE Discoid
Date of diagnosis Treatment

MonthDayYear
Date
5. Are you currently receiving Physical Therapy?
If yes, explain
6. Are you currently receiving any type of joint injections?
If yes, explain
7. Do you have any musculoskeletal conditions?
If Yes, What Type and Date of Diagnosis
Current Treatment(s)
8. Do you currently take any narcotic medications for pain?
If Yes, What is the Pain Causing Condition(s)?
Medication Name(s), Dosage, and Frequency
9. Have You Ever Been Diagnosed with:
If Yes, Date of Diagnosis

MonthDayYear
Date
10. Are you currently collecting disability?
If Yes:
11. If Retired, Did You Collect SSI and go Directly to SS?
12. Have You Been Declined for Long Term Care Insurance (LTC) or a LTC Rider in the Past?
If yes, date of decline

MonthDayYear
Date
Client Signature:
Signature
Date
Spouse's Signature:
Signature
Date
Should be Empty:

Long Term Care Questionnaire

CLIENT INFORMATION

MEDICATIONS

HOSPITALIZATIONS

Long Term Care Supplemental Questionnaire

Client Signature:

Spouse's Signature: