Long-term care / chronic illness quote request
Advisor information
Advisor's name
Advisor's MVP Contact
Please select...
Dawn Nelson
Matt LaLonde
Joe Carey
Jim Chrisler
Fred Thorbahn
Jodi Waldera
Michael Zingale
Scott Thorp
Mary Lou Paul
Other / None of the above
Advisor's email address
Advisor's cell phone
Health licensed in state of
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
LTC training/education expiration
Optional for quotes, but must be up to date to submit application(s)
Quoting information
Purpose of coverage
Quoting companion's name
Quoting companion's relationship to applicant
Applicant's information
Applicant's name
Applicant's gender
Applicant's date of birth
Applicant's resident state
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
If applicant is currently receiving disability benefits, provide type/reason
Ever filed for bankruptcy?
Yes
No
Bankruptcy information
File date
Chapter
Completed date
Ever previously declined for LTC insurance?
Yes
No
Please provide details of previous decline(s)
Insured's personal health information
Height
ft
in
Weight
lbs
Has proposed insured had any weight change in excess of 10 lbs
.
in the past year?
Yes, lost weight
Yes, gained weight
No
Change amount
lbs
Reason(s) for weight change
Tobacco / Nicotine use
Yes
No
Tobacco / nicotine use information
Type(s) used
Cigarettes
Cigars
Pipe
Chewing tobacco
Nicotine vape
Non-vape nicotine product (gum, pouch, patch)
Frequency of use
Date of last use
Back / neck problems?
Yes
No
Back / neck problem information
Chiropractic
Date last seen
Details
Is proposed insured diabetic?
Yes
No
Diabetes information
Type
Age onset
Details
Has proposed insured had a sleep study / disorder?
Yes
No
Sleep study / disorder information
Disorder (e.g. apnea, respiratory)
C-pap use?
Details
Hypertension?
Yes
No
Hypertension information
Date diagnosed
Last reading
Reading
date
Cancer?
Yes
No
Cancer information
Type
Location
Last treatment date
Drug / alcohol abuse?
Yes
No
Drug / alcohol abuse information
Type
Amount
Treatment date(s)
Has proposed insured ever used any of the following (check all that apply)
Cane / Walker
Crutches
Wheelchair
When?
Any medications?
Yes
No
Medication information
Rx name
Dosage
Date prescribed
Please check all that apply to applicant
Handicap parking permit
Heart disease
Carotid artery disease
Peripheral vascular disease
Blood clots/embolism
Depression/mental illness
Chronic fatigue/fibromyalgia
Crohn's/colitis/gastric bypass
Back/spine disorders
Osteoporosis/fractures
Visual impairments/loss
Any hospitalizations
Any physical therapy
Transient ischemia attack
Stroke/CVA
Alzheimer's/dementia
Memory loss/forgetful
Kidney disease
Liver disorders
Arthritis
Seizure disorders
Case design
Traditional LTC or LTC/CI Life Hybrid?
Traditional LTC
LTC/CI Life Hybrid
Life death benefit amount
$
Elimination period requested
Benefit period requested
Options requested
Partial/Residual
Cost of living
Future purchase rider
Retirement plan deferral
Automatic increase
Future purchase rider amount
$
Retirement plan deferral amount
$
Automatic increase
Additional information: Please list any additional comments, requests or information that will assist us in properly preparing your quote (including riders, premium paying years, etc.).
Contact Information