Long Term Care Insurance Quote Questionnaire

Agent*

Choose the Agent You are Working With

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-Mail*

Email

Date of Birth*

Height*

Weight*

Smoker*

US Citizen? If no, permanent Resident?*

Reason*

Have EVER been diagnosed or tested positive for Human Immunodeficiency Virus (AIDS Virus) or Acquired Immune Deficiency Syndrome (AIDS)? If Yes, Type, Date Diagnosed, Medication Taken and Dosage*

Have EVER been diagnosed or treatment for heart disease, including: heart attack; coronary artery blockage; angina; heart failure; cardiomyopathy; irregular heartbeat; or disease or disorder of the heart? If Yes, Type, Date Diagnosed, Medication Taken and Dosage*

Have EVER been diagnosed or treatment for stroke, transient ischemic attack (TIA/mini-stroke), carotid artery disease, peripheral vascular disease, poor circulation, aneurysm, or any other disease or disorder of the blood vessels? If Yes, Type, Date Diagnosed, Medication Taken and Dosage*

Have EVER been diagnosed or treatment for cancer, tumor, abnormal growth, lump, mass, melanoma, lymphoma, or leukemia? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Have EVER been diagnosed or treatment for anemia, clotting disorder, or any disease or disorder of the blood? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Any diseases or disorders of the immune system except for those related to Human Immunodeficiency Virus (AIDS Virus)? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

High Blood Pressure? If Yes, Date Diagnosed, Medication Taken and Dosage*

Diabetes? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Asthma, chronic bronchitis, Chronic Obstructive Pulmonary Disease (COPD), emphysema, sleep apnea, tuberculosis, or any disease or disorder of the lungs? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Gastrointestinal bleeding, ulcers, Crohn’s disease, Barrett’s esophagus, ulcerative colitis, hepatitis, cirrhosis, colon polyps, or any otherdisease or disorder of the esophagus, stomach, intestines/colon, rectum, liver or pancreas? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Any disease or disorder of the kidneys, urinary bladder, blood in urine, protein in urine, prostate disorder including abnormal PSA(prostate specific antigen), ovaries, uterus, or cervix including abnormal Pap smear? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Disorder of the thyroid, pituitary gland, parathyroid glands, or adrenal glands? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Arthritis, fibromyalgia, chronic pain, chronic back pain, or any joint or muscle condition? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Lupus, scleroderma, any connective tissue disease, or any autoimmune disorder? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Seizures/epilepsy, tremors, multiple sclerosis, paralysis, Alzheimer’s, dementia, Parkinson’s, blindness or any other disease or disorderof the brain or nervous system? If Yes, Date Diagnosed, Type, Medication Taken and Dosage*

Depression, Anxiety, attention deficit/hyperactivity disorder, bipolar disorder, schizophrenia, post-traumatic stress disorder, or psychiatric treatment? If Yes, Date Diagnosed, Type, Medication Taken and Dosage. Contemplated Suicide?*

Had any consultation, testing, surgery or investigation scheduled or recommended by a member of the medical profession that has not yetbeen completed (excluding routine checkups, preventative care, pregnancy and HIV)? If Yes, Date, Type, Medication Taken and Dosage*

Applied for or received any disability benefits (other than maternity) from any insurance company, government, employer, or other source? If Yes, Date, Reason*

Taken any prescription medications other than what has already been disclosed on the application? If Yes, Date, Reason*

Use Marijuana in any form? If Yes, Reason*

Been advised by a licensed medical professional to cease or reduce alcohol use or been advised to get medical treatment, or undergoneany medical treatment, counseling, or hospitalization for alcoholism, excessive alcohol use or abuse? If Yes, Reason*

Long Term Care Insurance Quote Form

MEDICAL QUESTIONS

DRUGS/ALCOHOL HISTORY