|
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:
|
|
What is your
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:
Are you legally
married, living
with a domestic
partner, or
single?
|
|
If you are living
with a domestic
partner, how long
have you been
living in the same
residence?
|
|
What benefits do
you want in your
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 years
-
10 years
-
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
|
|
Do you
already have a
long term care
insurance policy?
If so, how long
have you
had this policy
and briefly
explain
what benefits it
has? Why are
you considering a
new policy? |
|
Do you think it is
likely that you 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 me
and I 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.
b) I'm not sure
if long term care
insurance is
right for me. 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 your long
term care
insurance policy? |
|
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
|
Are you aware of
the possible tax
advantages of
having your
business pay long
term care
insurance
premiums?
|
|
How is your
health?
13 Heath
Questions:
Why do I need you to answer
these health questions?---CLICK
HERE
What prescriptions
do you
take? |
|
What health
condition causes
you to
take each prescription? |
|
When did you 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 you height? |
|
What is your
weight
now?
Approximately,
what was your
weight this time
last year? |
|
When was the last
time you had a
physical? If
it was more than a
year ago, when was
the last time you
saw a medical
doctor for
any other reason?
|
|
Have you
been hospitalized
or had any type of
surgery in the
last 5 years? If
so, when and why?
|
|
Have you
ever had any type
of cancer?
If so, what kind
of cancer was it?
When did you
receive
the final cancer
treatment? |
|
Have you ever had
any type of stroke
or mini-stroke?
If so, how many
strokes or
mini-strokes have
you
had,
when was the last
one, and are there
any residual
effects (e.g.
impaired vision,
paralysis,
cognitive
impairments). |
|
|
Have you
had any major
injuries, falls or
broken bones in
the last 5 years?
If so, please
provide details. |
|
Do you have any
other chronic
illnesses? Have
you experienced
any severe memory
loss or any memory
loss requiring
medication? Give
as much detail as
possible, please |
|
Are you
currently
receiving any type
of
disability payments or
worker's
compensation
payments? If so,
what is the cause
of disability? |
|
What is your
date of birth? |
