LONG TERM CARE QUESTIONNAIRE

LONG TERM CARE QUESTIONNAIRE
Agent’s Name*
Agent’s Phone*
Format: (000) 000-0000.
Agent's Email*
example@example.com
Client Name*
Client D.O.B.*

MonthDayYear
MaleFemale
Marital Status*
YesNo
State*
Desired Monthly Benefit*
Desired Benefit Duration*
Additional Policy specs you want included
Height*
Weight*
YesNo
• If yes, how much ____ lbs. ?
Traditional Long Term CareGuaranteed Issue Long Term CareLife with Long Term CareAnnuity with Long Term CareAnnuity Income Rider with Chronic Benefit (Guaranteed issue)
YesNo
• If yes, give form and frequency
YesNo
• If yes, when
YesNo
• If yes, list family relation and diagnosis
YesNo
• List any prescribed medications taken (include dosage, frequency, and purpose)
• List any prescribed medications taken (include dosage, frequency, and purpose)
• List any prescribed medications taken (include dosage, frequency, and purpose)
• List any prescribed medications taken (include dosage, frequency, and purpose)
YesNo
• If yes, current reading, highest reading: BP
YesNo
• If yes, current reading, highest reading: Chol
• HDL reading or ratio
YesNo
• If yes please detail:
YesNo
• Date Diagnosed?

MonthDayYear
Date
• Treatment:
• Cancer type and stage?
YesNo
• Date Diagnosed?

MonthDayYear
Date
• Type (1 or 2) and last A1C reading?
YesNo
• Date Diagnosed?

MonthDayYear
Date
• Type (attack, bypass, stent, etc.)?
YesNo
• Date Diagnosed?

MonthDayYear
Date
• What is current treatment (CPAP, surgery, etc.) and current AHI?
YesNo
• Date Diagnosed?

MonthDayYear
Date
• Last date of in-treatment?

MonthDayYear
Date
YesNo
• If yes, provide details
YesNo
• If yes, results:
YesNo
• If yes, provide details
YesNo
YesNo
List other illnesses or impairments (if applicable):
YesNo
YesNo
• If yes, when, where and for what duration?
The above information is for preliminary underwriting purposes only and will not be made part of any contract.
Should be Empty: