Long Term Care Insurance

Client Information

Full Name*

Address*

Phone*

Email*

DOB*

Monthly Benefit Amount
$3000 $6000 $8000 $10000

Preferred Elimination Period
30 Days 60 Days 90 Days

Preferred Benefit Period
3 Years 5 Years 10 Years Unlimited

Preferred Modal Premium
Monthly Quarterly Annually

Medical Information

Height*

Weight*

Tobacco User? Yes

Medical History

Check the box if you have any history of the problem

Medications Taken, dosage & reason

Other medical conditions not listed here

High Blood Pressure Heart Disease Circulatory Conditions Blood/Protein in Urine Mental/Nervous Condition Bones/Joints/Skin	Fatigue Stress Anxiety Depression Diabetes Back/Neck	Thyroid Cancer Tumors Cyst Asthma Respiratory
Do you have any activity limits or use of assitive devices?	Have you ever received home are or been confined to a nursing home or rehabilitation center?	Are you currently receiving Social Security or disability benefits?