Request for a Personalized Long Term Care Insurance Policy Comparison

For Your Relative

 

 


In order to provide you with accurate quotes for long term care insurance for your relative, I will need you to provide me the following:
 

  1. general information about you

  2. general information about your relative

  3. which benefits do you want in the policy

  4. some basic information about your relative's health
     

Method of Compensation and Privacy Statement


General Information About You:

Your Name:

Your Street Address:  (no post office boxes, please)
Your City:
Your State:
Your Zip:

Your Daytime Phone:
Your Evening Phone:
 
The best time to call you with any questions is:
 
Your preferred e-mail address:
How often do you check this e-mail address:
 

 

General Information About Your Relative:

Your Relative's Name:


Your Relative's Street Address:
Your Relative's City:
Your Relative's State:
Your Relative's Zip:
 

How are you related to this person?

 

What is your relative's official state of residence?

 

NOTE:  Many insurers offer discounts of 10% to 50% when married couples or domestic partners apply together for long term care insurance.  Some insurers even give these discounts when only one spouse/partner is applying for coverage. 

To make sure I provide you with accurate premium calculations and recommendations, please answer the following two questions:

Is your relative married, living with a domestic partner or single?
If your relative is living with a domestic partner, for how long have they been living in the same residence?

 

 

What benefits do you want in the policy?
11 Policy Design Questions:

What type of policy do you want?

  • Integrated
  • Facility Only
  • Home Healthcare Only

 
How much of a Nursing Home Daily Benefit do you want?
How much of an Assisted Living Facility Daily Benefit do you want?
How much of a Home Healthcare Daily Benefit do you want?
 

What type of Inflation Benefit do you want?

  • No Inflation Benefit
  • Future Purchase Options
  • Automatic Inflation Benefit (if so, which type)

 

 
 

Which Benefit Period do you want?

  • 3 years
  • 4 years
  • 5 years
  • 6 others
  • lifetime/unlimited
  • Other

 

 

Is it very important for you to have a policy that could pay benefits for short-term needs at home?  (e.g. if your relative were to need care at home for less than 90 days)
 

How long of an Elimination Period do you want?

  • 0 days
  • 30 days
  • 60 days
  • 90 days
  • Other

 
Does your relative already have a long term care insurance policy?  If so, how long has your relative had this policy and briefly explain what benefits it has?  Why are you considering a new policy?
Do you think it is likely that your relative may choose to
live outside the United States?  If so, would you want a long term care policy that would pay benefits for care that’s received outside the United States?

 

Which of these statements most accurately describes your thoughts on long term care insurance? 

a)  I've decided that long term care insurance is definitely right for my relative and we plan on purchasing a policy within 3 months or so.  Right now I'm looking for information to help me choose the policy that's best for my relative.

 b)  I'm not sure if long term care insurance is right for my relative.  To help me decide, I want to see what kind of benefits are available and at what cost. 

 c)  Right now I want some information about costs and benefits so that I can better plan on when to move forward with a policy.  It will probably be at least six months to a year before I plan on purchasing the policy. 

 
Is there anything else that is very important for you to have in the long term care insurance policy for your relative?

 

FOR BUSINESS OWNERS ONLY:  
Does your relative own a business?  If so, what type of 
business entity is it for tax-filing purposes? 

a)  Sole Proprietorship

b)  Partnership

c)  S-Corporation

d)  C-Corporation


 
Are you aware of the possible tax advantages of having your business pay long term care insurance premiums? 

 



How is your relative's health?
13 Heath Questions:

Why do I need you to answer these health questions?---CLICK HERE

What prescriptions does your relative take?
What health condition causes your relative to take each prescription?
When did your relative last use a tobacco product?  What kind of tobacco product was it?  (If it was over 5 years ago, then just enter 'not applicable')
What is your relative’s height?
What is your relative’s weight now?  Approximately, what was your relative’s weight this time last year?
When was the last time your relative had a physical?  If it was more than a year ago, when was the last time your relative saw a medical doctor for any other reason? 
Has your relative been hospitalized or had any type of surgery in the last 5 years?  If so, when and why?
Has your relative ever had any type of cancer?  If so, what kind of cancer was it?  When did your relative receive the final cancer treatment?
Has your relative ever had any type of stroke or mini-stroke?  If so, how many strokes or mini-strokes has your relative had, when was the last one, and are there any residual effects (e.g. impaired vision, paralysis, cognitive impairments).  

Has your relative had any major injuries, falls or broken bones in the last 5 years?  If so, please provide details.

Does your relative have any short-term memory problems?  Does your relative have any other chronic illnesses?  Please give as much detail as possible.

Is your relative currently receiving any type of disability payments or worker's compensation payments?  If so, what is the cause of disability?
What is your relative’s date of birth?

Click on the 'OK' button and I'll get to work on your personalized long term care insurance comparisons.  I will have my recommendations ready for you to view online within 2 to 3 business days.


Joe Gahm
Phone:  (443) 880-2600