Long Term Care Quote Request

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Personal Information

Name DOB
Spouse DOB
Address  
City State, Zip
Phone Chamber of Commerce or Association Affiliation, If Any...
Business

Please answer the questions below to help 
us provide you with the best product options available.

1. Are you currently covered by Medicaid?
2. Have you ever had, been told by a physician that you have, or been diagnosed as having any one of the following conditions?

Acquired Immune Deficiency Syndrome (AIDS)
AIDS Related Complex (ARC)
Alzheimer’s Disease 
Amputation Due to Disease
Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)
Chronic Hepatitis
Cirrhosis of the Liver 
 Dementia or Organic Brain Syndrome
Hydrocephalus 
 Multiple Sclerosis
Multiple Strokes, CVAs or TIAs
Muscular Dystrophy
Myasthenia Gravis 
Osteoporosis WITH compression Fractures
Paraplegia or Quadriplegia 
Parkinson’s diseases

  
3. During the past 3 YEARS, have You been told by a physician that You have, or have been diagnosed as having:  Diabetes using over 50 units of insulin or WITH COMPLICATIONS (Neuropathy, Retinopathy, Amputations), Alcoholism, alcohol abuse drug or prescription drug addiction, Transient Global Amnesia or memory loss requiring medication?
4. Do You CURRENTLY use: a catheter, dialysis, oxygen equipment, a quad  or three-pronged cane, respirator, walker,  wheelchair, crutches, motorized scooter or chair lift?
5. Do You need  assistance or supervision of any kind to perform everyday living  activities:  dressing, eating, walking, bathing, transferring, toilet activities or taking  medication?
6. During the past 6 MONTHS,  have You been confined to a nursing home, assisted living facility or attended any adult day care facility?
7. In the past 3 YEARS, have You been declined long term care insurance?
If Yes, What Company? When?
Why? (if known)