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REQUEST LONG TERM CARE INSURANCE QUOTE

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Your Information
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Primary Insured   Spouse/Partner
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Male    Female Gender Male    Female
Last Tobacco Use
Surgeries past 5 yrs
Daily Benefit:
Benefit Duration:
Elimination Period:
Inflation Protection:
Benefit Type:
Has the client been treated for any of the following conditions in the last 5 years?
Primary
Insured		 (check all that apply) Spouse /
Partner
High Blood Pressure
Heart Attack, Angina, Angioplasty or Atria Fibrillation
Stroke or TIA
Arthritis
Type I Diabetes (insulin)
Type II Diabetes (oral meds)
Neuropathy or Retinopathy
Osteoporosis (list T-Score below)
Compression Fractures
PSA (prostate test) for men (list score below)
Cancer (list type and treatment below)
Fibromyalgia
Anxiety/Depression
Lupus (list type below)
Please list other health issues or any relevant details on above conditions
Also, please list any prescription Meds & Dosages, with Reason prescribed
Primary Insured
 Spouse/Partner
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