Long-Term Care Insurance Pre-Assessment Form

1

Please verify that you are human* This field is required.

2

Name

First Name

Last Name

3

Address*City and Province Required

Street Address (Optional)

Street Address Line 2 (Optional)

*City (Required)

*State / Province (Required)

Postal / Zip Code (Optional)

Country

4

Email

example@example.com

5

Phone Number

Please enter a valid phone number.

6

Date of Birth

Date

7

Gender

8

Do you currently live:

Independently

With Family

In a Retirement/Assisted Setting

Other

9

Do you have a family member or caregiver who helps you with your daily activities?

YESNO

10

Have you ever been diagnosed with or treated for any of the following?Select all that apply

Alzheimer's Disease or Dementia

Parkinson's Disease

Stroke or Neurological Disorder

Mobility Impairment or Chronic Pain

Other

11

Do you have any other serious/chronic illness?

YESNO

12

If yes, please specify your other serious/chronic illness.

13

Do you currently have any long-term care coverage through work or personally?

YESNO

14

What is most important to you in a Long-Term Care plan?

Protecting savings and assets

Having choice of care setting (home care vs. facility)

Reducing burden on family

Comprehensive coverage for nursing or personal care

Other