Please complete your HIPAA Compliant Long Term Care Questionnaire! After you submit the questionnaire you will be redirected to a webpage to schedule an appointment if desired. Long-Term Care Questionnaire Long Term Care Insurance is medically underwritten. This means that your health history determines if you are eligible to purchase coverage. We would like to ask some health question first in order to determine insurability. Kindly answer the questions below and provide as much detail as possible. After you submit the questionnaire, you will be redirected to a webpage to schedule an appointment. First Name(Required) Last Name(Required) Email Address(Required) Phone Number(Required) Address(Required) City(Required) State(Required) Zip(Required) Would you like to shop coverage for a spouse/partner as well?(Required) Yes No Spouse/Partner InformationFirst Name(Required) Last Name(Required) Email Address(Required) Phone Number(Required) YOUR Medical InfoHeight and Weight(Required) Tobacco Use in the last 12 months?(Required) Yes No Family History of Dementia or Alzheimer's(Required) 1 Biological parent or sibling 2 or more biological parents or siblings No family history of Dementia or Alzheimer's Congestive Heart Failure(Required) Yes No Heart Attack, Stroke or TIA(Required) Yes No Details on CHF, Heart Attack, Stroke or TIA including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Internal Cancer or Melanoma(Required) Yes No Atrial Fibrillation(Required) Yes No Details on Cancer or A-Fib including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Diabetes(Required) Yes No Diabetes with insulin use(Required) Yes No Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)(Required) Yes No Please provide any additional details about diabetes including how long you have had it, have your medications changed in the last 12 months, A1C levels, etc(Required)Arthritis , History of injections, Joint pain or Joint replacement(Required) Yes No Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)(Required) Yes No Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis(Required) Yes No Details on Arthritis, Liver, Osteoporosis, Parkinsons, Arthritis or MS including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Any physical, occupational or speech therapy- in past 6 months, current, or recommended?(Required) Yes No Any scheduled or recommended surgery or treatment in next 12 months?(Required) Yes No Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc(Required)SPOUSE/PARTNER'S Medical InfoHeight and Weight(Required) Tobacco Use in the last 12 months(Required) Yes No Family History of Dementia or Alzheimer's(Required) 1 Biological parent or sibling 2 or more biological parents or siblings No family history of Dementia or Alzheimer's Congestive Heart Failure(Required) Yes No Heart Attack, Stroke or TIA(Required) Yes No Details on CHF, Heart Attack, Stroke or TIA including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Internal Cancer or Melanoma(Required) Yes No Atrial Fibrillation(Required) Yes No Details on Cancer or A-Fib including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Diabetes(Required) Yes No Diabetes with insulin use(Required) Yes No Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)(Required) Yes No Please provide any additional details about diabetes including how long you have had it, have your medications changed in the last 12 months, A1C levels, etc(Required)Arthritis , History of injections, Joint pain or Joint replacement(Required) Yes No Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)(Required) Yes No Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis(Required) Yes No Details on Arthritis, Osteoporosis, Parkinson's, RA or MS including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Any physical, occupational or speech therapy- in past 6 months, current, or recommended?(Required) Yes No Any scheduled or recommended surgery or treatment in next 12 months?(Required) Yes No Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc(Required)
