Life & Long-Term Care Pre-Qualification Questionnaire

Life & Long-Term Care Pre-Qualification Questionnaire

Please complete all sections of this medical questionnaire as accurately as possible. Your responses are confidential and will be used for assessment purposes.
Applicant Details
Last Name
First Name
Middle Initial
Legal Residence Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number (Primary)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Alternate)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security Number (Optional)
Birth Date

MonthDayYear
Date
Age
Sex at Birth
Driver’s License Number, State Issued & Expiration
Occupation & Retirement Planning
Birth City and State
Citizenship Status

Other
Within the past 5 years, have you been declined, postponed, or charged an extra premium for life, health, or disability insurance?
If YES, explain
What insurance do you currently have? For example, life insurance (whole life or term, date issued and expiration), long-term care, Disability Income Replacement, Medicare/Health Insurance or chronic illness insurance?
Current Health Insurance (Employer-Sponsored, or ACA HMO/PPO) or Medicare Plan (Medicare Supplement or Medicare Advantage Plan):
Current Life Insurance, Term or Whole Life, Face amount, expiration date and premium.
Do you have a Whole Life Insurance policy, IUL or annuity that would be eligible for a 1035 exchange to maximize benefits without tax consequences? For example, a cash balance on a whole life insurance policy of $50,000 may be able to be respositioned into a long-term care policy of $150,000.
Disability Income Replacement (long-term or short term)
Current Long-Term Care Plan (i.e. kids will take care of me, I want to stay in my current house, etc). Current Long-Term Care policy, coverage and premium.
Do you have a guaranteed lifetime income stream (other than social security), and if so, will that income double if you need assistance with activities of daily living? If yes, describe. If no, would you like to review this option?
Health History
Height
Weight
Has your weight changed by more than 10 lbs in the past year?
Please explain the change in weight.
Have you ever been diagnosed with or treated for any of the following conditions?

Other
If you answered 'Other', please specify
Medication Details
What is your last A1C? Do you take more than 50 units of insulin daily?
Has any immediate family member had any of the following?
If yes on Dementia Alzheimers, was the family member over the age of 79?
In the past 24 months have you had any tests, treatments or surgeries?
Have you been to Urgent Care, Emergency Room or hospitalized in the past 24 months? If so, what is the date and the reason?
If yes, please describe (include dates, hospital, reason)
In the past 24 months, have you ever been advised to have a test, treatment, or surgery that was not completed?
If yes, please explain
Primary Physician Name
Do you have any tests or surgeries scheduled? Are you actively participating in physicial therapy?
Primary Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Physician Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Last Seen Date

MonthDayYear
Date
Reason for last visit
How often do you have a Well-Care Check-up? (for certain policies you must have had been to the doctor for well care within the past two years).
Substance Use
Do you currently use tobacco products?
Do you consume alcohol?
If yes, specify frequency and amount
Do you use any recreational drugs?
If yes, specify type and frequency
Medication Details
Medications
Medication Details
Appointment Options [unless already scheduled]
What are your main goals in meeting with our team? For example, Long-Term Care Quotes & Comparison, Life Insurance Quotes or Personal Pension Account Options, Medicare, Health Insurance, Cancer/Heart/Stroke, Accident, Disability Income Replacement, other.
What are your greatest concerns in this stage of your planning process? I.e. living too long, running out of money, dying too soon, being a burden on family, quality of care when I need assistance with activities of daily living, leaving debt for family, leaving a legacy.
What other research have you done to protect this risk? I.e. other advisors, other quotes & comparisons, internet research.
What is your life expectancy? See Calculator: https://www.livingto100.com/calculator
Signature
Date

MonthDayYear
Date
Should be Empty:

Life & Long-Term Care Pre-Qualification Questionnaire

Applicant Details

Health History

Substance Use

Medication Details