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Your Name: |
Your Street Address:
(no post office
boxes, please)
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Your City:
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Your State:
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Your Zip:
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Your Daytime
Phone:
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Your Evening
Phone:
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The best time to
call you with any
questions is:
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Your preferred
e-mail address:
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How often do you
check this e-mail
address:
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General
Information About
Your Spouse:
Your Spouse's
Name:
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What is your
spouse's official
state of
residence?
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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:
Are you legally
married or living
as a domestic
partnership?
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If you are living
with a domestic
partner, how long
have you been
living in the same
residence?
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Is there a
specific reason
why you want a
long term care
insurance policy
for your
spouse/partner
only and not for
yourself as well?
Do you currently
have a policy?
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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
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How much of a
Nursing Home
Daily
Benefit do you
want? |
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How much of an
Assisted Living
Facility
Daily
Benefit do you
want? |
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How much of a
Home Healthcare
Daily
Benefit do
you want? |
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What type of
Inflation Benefit
do you want?
-
No Inflation
Benefit
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Future Purchase
Options
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Automatic
Inflation
Benefit (if so,
which type)
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Which
Benefit
Period do you
want?
-
3 years
-
4 years
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5 years
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6 years
-
10 years
-
lifetime/unlimited
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Other
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Is it very
important for you
to have a policy
that
could pay benefits for
short-term needs
at home?
(e.g. if your
spouse/partner were to
need care at
home for less than
90 days)
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How long of an
Elimination Period
do you want?
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0 days
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30 days
-
60 days
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90 days
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Other
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Does your
spouse
already have a
long term care
insurance policy?
If so, how long
has your spouse
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
spouse 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? |
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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 spouse
and we plan on
purchasing a
policy within 3
months or so.
Right now we're
looking for
information to
help us choose the
policy that's
best.
b) I'm not sure
if long term care
insurance is
right for my
spouse. To
help us decide, we
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
we
can better plan on
when to move
forward
with a policy. It
will probably be
at least six
months to
a year before
we
plan on purchasing
the policy.
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Is there anything
else that is very
important for you
to
have in the long
term care
insurance policy
for
your spouse? |
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FOR BUSINESS
OWNERS ONLY:
Do you or your
spouse
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
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Are you aware of
the possible tax
advantages of
having your
business pay long
term care
insurance
premiums?
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How is your
spouse's health?
13 Heath
Questions:
Why do I need you to answer
these health questions?---CLICK
HERE
What prescriptions
does your spouse
take? |
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What health
condition causes
your spouse to
take each prescription? |
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When did your
spouse last use
a tobacco product?
What kind of
tobacco product
was it? (If
it was over 5
years ago, then
just enter 'not
applicable')
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What is your
spouse’s height? |
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What is your
spouse’s weight
now?
Approximately,
what was your
spouse’s
weight this time
last year? |
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When was the last
time your
spouse
had a physical?
If it was more
than a year ago,
when was the last
time your
spouse
saw a medical
doctor for
any other reason?
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Has your
spouse
been hospitalized
or had any type of
surgery in the
last 5 years? If
so, when and why?
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Has your
spouse
ever had any type
of cancer?
If so, what kind
of cancer was it?
When did your
spouse
receive
the final cancer
treatment? |
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Has your
spouse
ever had
any type of stroke
or mini-stroke?
If so, how many
strokes or
mini-strokes has
your
spouse
had,
when was the last
one, and are there
any residual
effects (e.g.
impaired vision,
paralysis,
cognitive
impairments). |
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Has your
spouse
had any major
injuries, falls or
broken bones in
the last 5 years?
If so, please
provide details. |
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Does your
spouse
have any
short-term memory
problems?
Does your
spouse
have any other
chronic
illnesses?
Please give as
much detail as
possible. |
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Is your
spouse
currently
receiving any type
of
disability payments or
worker's
compensation
payments? If so,
what is the cause
of disability? |
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What is your
spouse
’s date of
birth? |
