Long Term Care Quote
Please answer the questions below in order to get the most accurate quote possible. Some questions may seem sensitive in nature, but the accuracy of your answers will determine the accuracy of your quote.
Basic Information
Insured's age
Spouse"s Name
Spouse's age:
Health Information
Insured
Spouse
Do you need assistance or supervision in performing any of the following actiivities: Bathing, Continence, Dressing, Eating, Toileting, Transferring?
Are you dependent on the use of a walker, wheelchair, quad or 4 prong cane, or motorized scooter, or are you confined to a bed, your home, a hospital, or nursing home, or do you use medical equipment such as oxygen, a respirator, or a dialysis machine?
Have you been diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex, Diabetes using over 50 units of insulin per day, or Diabetes with amputation or kidney problems?
Due to any mental or physical disablity, either current or past, is any person or institution currently authorized to act on your behalf?
During the past 12 MONTHS have you been diagnosed or treated for a Transient Ischemic Attack (TIA), Stroke, or Heart Attack; or have you used Nursing Home, Assisted Living Facility, Adult Day Care, or Home Care services?
During the last 5 YEARS have you been diagnosed or treated for any of the following conditions?
- ALS (Lou Gehrig's Disease)
- Alzheimer's Disease
- Aneurysm (Cerebral)
- Central Nervous System Shunt
- Cerebral Vascular Disease
- Chronic Lymphocytic Leukemia
- Cirrhosis of the Liver
- Multiple Strokes
- Multiple Transient Ischemic Attacks (TIAs)
- Parkinson's Disease
- Dementia
- Huntington's Chorea
- Kidney Failure
- Memory Loss (recurring)
- Metastatic Cancer (cancer that has spread from the original site.
- Multiple Sclerosis (MS)
- Schizophrenia or Psychosis
- Systemic Lupus Erythematosus (SLE)
During the last 3 YEARS, have you been diagnosed, treated, or consulted with a member of the medical profession for any of the following conditions?
- Alcoholism or Drug Abuse
- Balance Disorders
- Cancer (excluding skin cancer)
- Carotid Artery Disease
- Chronic Bronchitis
- Chronic Depression with Medication
- Chronic Obstructive Pulmonary Disease
- Coronary Artery Disease
- Congestive Heart Failure
- Denegerative Joint/Disc Disease
- Diabetes
- Vertigo
- Dizziness
- Emphysema
- Fibromyalgia
- Irregular Heart Beat/Atrial Fibrillation
- Macular Degeneration
- Mental Disorder
- Osteoporosis
- Osteoarthritis with Drug Treatment
- Peripheral Vascular Disease
- Rheumatoid Arthritis
- Stroke
- Transient Ischemic Attack (TIA)
IMORTANT! Please read before you submit.
The information you are providing is strictly for the purpose of providing you with a quote for Long Term Care Insurance. All answers will be held in the strictest confidence and will not be shared. This is not an application for insurance. This is a request for an illustration only and there is no obligation of any kind to make offer or acceptance for insurance. An insurance policy is a legal document and should be discussed and reviewed thoroughly with a licensed professional in order to make informed decisions.
Long Term Care Insurance is an important tool when planning for Long Term Care. There are other tools available that can be very valuable in the planning process. Would you like to receive free information on other Long Term Care planning options?
American Retirement Counselors
Because A Great Retirement Starts With Great Planning
