PERSONAL PROFILE FORM

PERSONAL PROFILE FORM

To ensure that we provide you with the most suitable planning solutions, it is essential to have accurate information regarding medically underwritten Long Term Care plans. Your privacy is of utmost importance to us, which is why these forms are HIPAA protected. Rest assured, only your Long Term Care agent will be granted access to this confidential information.
- Name
  
  First NameLast Name
- MaleFemaleNon Binary
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number (Home)
  Format: (000) 000-0000.
- Phone Number (Work)
  Format: (000) 000-0000.
- Phone Number (Cell)
  Format: (000) 000-0000.
- Email
- Date of Birth
  
  MonthDayYear
  Date
- SingleMarriedDomestic PartnerOther
- YesNo
- YesNo
- Spouse/Partner Name
  
  First NameLast Name
- Spouse/Partner Date of Birth
  
  MonthDayYear
  Date
- Health Screening Questions
  
  In order to better serve you, we need you to first complete this health screening questionnaire.
  
  Long Term Care plans are health underwritten. If it is in your doctor's records please list it here.
- ExcellentGoodFairPoor
- Height
- Weight
- Alzheimer’s diseaseAmyotrophic Lateral SclerosisCystic FibrosisDementiaHuntington’s ChoreaMemory LossMental RetardationMultiple MyelomaMultiple SclerosisMuscular DystrophyMyasthenia GravisParkinson’s diseaseSchizophreniaSclerodermaSpinal Cord InjuryStroke/CVA
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- Primary Care Physician Name
  
  First NameLast Name
- Primary Care Physician Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Primary Care Physician Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- YesNo
- Within the last 10 years, have you received medical advice, diagnosis, treatment, or consulted with a member of the medical profession for any of the following conditions?
- YesNo
- You Selected yes to Circulatory Disorders, please explain.*
- YesNo
- You Selected yes to Endocrine and Pituitary Disorders, please explain.*
- YesNo
- You Selected yes to Cancers, please explain.*
- YesNo
- You Selected yes to Genitourinary Disorders, please explain.*
- YesNo
- You Selected yes to Gastrointestinal Disorders, please explain.*
- YesNo
- You Selected yes to Neurological Disorders, please explain.*
- YesNo
- You Selected yes to Blood Disorders, please explain.*
- YesNo
- You Selected yes to Musculoskeletal Disorders, please explain.*
- YesNo
- You Selected yes to Respiratory Disorders, please explain.*
- YesNo
- You Selected yes to Eye & Ear Disorders, please explain.*
- YesNo
- You Selected yes to Substance Abuse, please explain.*
- YesNo
- You Selected yes to within the last 10 years have you been hospitalized or have you consulted or been treated by a member of the medical profession for any reason not previously stated, please explain.*
- YesNo
- You Selected yes to having ever had an application for life, accident, medical or health, disability or long-term care Insurance declined, postponed, modified or rated, please explain.*
- YesNo
- You Selected yes to currently receiving any physical therapy, or have you received any physical therapy within the last 3 months, please explain.*
- YesNo
- You Selected yes to currently taking any medications, or discontinued any medications within the past 6 months, please explain.*
- Spouse Health Screening Questions
  
  In order to better serve you, we need you to first complete this health screening questionnaire.
  
  Long Term Care plans are health underwritten. If it is in your doctor's records please list it here.
- ExcellentGoodFairPoor
- Height
- Weight
- Alzheimer’s diseaseAmyotrophic Lateral SclerosisCystic FibrosisDementiaHuntington’s ChoreaMemory LossMental RetardationMultiple MyelomaMultiple SclerosisMuscular DystrophyMyasthenia GravisParkinson’s diseaseSchizophreniaSclerodermaSpinal Cord InjuryStroke/CVA
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- If Yes, Please List Primary Care Physician Name
  
  First NameLast Name
- Primary Care Physician Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Primary Care Physician Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- YesNo
- Within the last 10 years, have you received medical advice, diagnosis, treatment, or consulted with a member of the medical profession for any of the following conditions?
- YesNo
- If yes to Circulatory Disorders, please explain.
- YesNo
- If yes to Endocrine and Pituitary Disorders, please explain.
- YesNo
- If yes to Cancers, please explain.
- YesNo
- If yes to Genitourinary Disorders, please explain.
- YesNo
- If yes to Gastrointestinal Disorders, please explain.
- YesNo
- If yes to Neurological Disorders, please explain.
- YesNo
- If yes to Blood Disorders, please explain.
- YesNo
- If yes to Musculoskeletal Disorders, please explain.
- YesNo
- If yes to Respiratory Disorders, please explain.
- YesNo
- If yes to Eye & Ear Disorders, please explain.
- YesNo
- If yes to Substance Abuse, please explain.
- YesNo
- If yes to within the last 10 years have you been hospitalized or have you consulted or been treated by a member of the medical profession for any reason not previously stated, please explain.
- YesNo
- If yes to having ever had an application for life, accident, medical or health, disability or long-term care Insurance declined, postponed, modified or rated, please explain.
- YesNo
- If yes to currently receiving any physical therapy, or have you received any physical therapy within the last 3 months, please explain.
- YesNo
- If yes to currently taking any medications, or discontinued any medications within the past 6 months, please explain.
- Please verify that you are human*
- If you have fully completed this form, please click the submit button below to send your information for processing. If you require additional time to gather your information, please click the save button, which will allow you to receive an email with a link to complete the form at a later time; no information will be submitted at this time.
- Should be Empty:

PERSONAL PROFILE FORM

Health Screening Questions

Within the last 10 years, have you received medical advice, diagnosis, treatment, or consulted with a member of the medical profession for any of the following conditions?

Spouse Health Screening Questions

Within the last 10 years, have you received medical advice, diagnosis, treatment, or consulted with a member of the medical profession for any of the following conditions?