Pre-Qualifying Health Questionnaire

  • This Health Form is HIPAA compliant to protect your personal information.

    (No need for exact dates - Month/Year is fine, or if more than a couple years, the estimated year is fine)
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  • Date of Birth*
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  • Gender*
  • Do you have a partner/spouse with whom you live?*
  • Would you like to consider a shared policy including your partner/Spouse?
  • Have you had a physical and a full panel of blood work in the last 2 years?*
  • Were any of your blood labs outside the range of normal?*
  • Do you have any medical appointments or tests pending (including those that still need to be scheduled)?
  • Have you been prescribed medications that you chose not to take or stopped taking without your MD discontinuing the recommendation or order?*
  • Do you currently have HIV/AIDS?*
  • Do you have ALS, Cirrhosis, Cystic Fibrosis, Huntington’s Chorea, Kidney Disease, Memory Issues, Muscular Dystrophy, Multiple Sclerosis, Parkinson’s, Schizophrenia, Systemic Lupus?*
  • Do you currently use: Cane, walker, wheelchair, electric scooter, stairlift, hospital bed, nebulizer, or oxygen?*
  • Have you been diagnosed with an aneurism?
  • Do you currently receive: Benefits under Disability Income, Medicaid, Social Security Disability, or Workers Compensation?*
  • Have any members of your immediate biological family (father, mother, or sibling) been diagnosed with Alzheimer’s or another form of Dementia or other potentially genetic chronic diagnosis?*

  • Past or Present:

  • Have you had an MRI in the last 5 years?*
  • Have you smoked tobacco products or marijuana within the last 24 months or use Marijuana gummies?*
  • Please check all that apply:*
  • Had/Have cancer?*
  • Had a stroke or a TIA?*
  • Had any major injuries, falls, mobility issues, or broken bones in the last 2 years?*
  • Do you have Osteoporosis?*
  • Have any other chronic illnesses? (i.e. Arthritis, Atrial Fibrillation, Chronic Bronchitis, COPD, Diabetes Type I, Diabetes Type II, Emphysema, Hypertension, etc.)*
  • Have Sleep Apnea?*
  • If yes, do you use a CPAP or other device regularly?*
  • Had/Have Cortisone or other kinds of steroid injections in the last 2 years?*
  • Had/Have Physical or Occupational Therapy in the last 2 years?*
  • Had/Have any substance abuse history with either alcohol or drugs?*
  • Had/Have any Depression and/or Anxiety history in the last 5 years?*
  • Do you have any residual symptoms from COVID or Lyme Disease?*
  • Had/Have any other health issues, surgeries, or treatments not mentioned above in the last 3 years?*

  • Financials

  • Do you own or rent?*
  • Do you have a second property?*
  • What other insurances do you presently own?*
  • Is it important to leave assets to:*
  • Are you self-employed or own a business?*
  • What is your annual income ?*
  • Are you retired or when do you plan to retire?*
  • Do you have an HSA account?*
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  • If you had to take a guess, when do you think you might need care?*
  • If you need care, how many years would you want to be sure you could afford to fund?*
  • What do you feel you could afford on an annual premium basis if you saw the value?*

  • Other

  • Have you looked at long term care insurance previously?*
  • Are you presently looking at long term care insurance with another source?*
  • Have you been declined for long term care insurance in the past?*

  • NOTE: Please make sure to click SUBMIT above to ensure your information has been sent. You will receive an email confirmation a few minutes later which confirms your entry was submitted.

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