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Long Term Care Insurance Quotes
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(703) 986-0468
Long Term Care Insurance Quotes
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Personal Information
Insured's Name:
*
First
Last
Date Of Birth:
*
MM slash DD slash YYYY
Gender:
*
Male
Female
Tobacco User:
*
Yes
No
US Citizen/Green Card:
*
Yes
No
Marital Status:
*
Married
Single
Height:
*
Weight:
*
Address:
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Louisiana
Maine
Maryland
Massachusetts
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North Carolina
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is the mailing address the same as the physical address?
*
Yes
No
Mailing Address:
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone:
*
Best Time To Call:
Email:
*
How Did You Hear About Us?
Please check all that apply:
Search Engine
Social Network
Forum/Blog
Advertisement
Family or Friend
Coworker
Other
Other:
Current/Previous Insurance Information
Do you currently have another Long-Term Care insurance policy, rider or certificate (including health care service contract or health maintenance organization contract)?
Yes
No
Did you previously have another Long-Term Care insurance policy, rider or certificate in force during the last 12 months?
Yes
No
If so, when did it lapse (mm/dd/yy):
MM slash DD slash YYYY
Are you covered by a state assistance program (Medicaid)?
Yes
No
Do you intend to replace any of your medical or health insurance coverage with this policy, rider or certificate?
Yes
No
Are you now receiving long-term care or disability benefits?
Yes
No
Have you ever been denied coverage for medical insurance, disability insurance, long-term care insurance, nursing home insurance, or life insurance?
Yes
No
If "Yes", please explain:
Activities Information
Have you been confined to a hospital in the last 12 months?
Yes
No
Has a physician recommended in the past 24 months that you be hospitalized or confined to a nursing facility, or that you have a surgical procedure?
Yes
No
Have you consulted with a physician in the last 12 months for loss of appetite, falling, unstable gait, bladder or bowel control, dizziness or vision problems, or weight loss of 10 pounds or more?
Yes
No
Do you need the help or supervision of another individual to perform your everyday living activities such as walking, dressing, eating, taking medications or tending to personal hygiene?
Yes
No
Do you need the help or supervision of another individual to perform the independent activities of daily living such as handling your finances, doing laundry, shopping or using the telephone?
Yes
No
Do you use any assistive devices such as a walker, wheelchair, crutches, cane, grab bars or any prescribed medical device or applicance?
Yes
No
If "Yes", please explain:
Medical Information
In the past 5 years have you ever had, been told by a physician you had, or been treated for the following:
Osteoarthritis, osteoporosis, amputation, bone or joint disease, rheumatoid arthritis, or spinal stenosis?
Yes
No
Internal cancer, tumor, leukemia, lymphoma, or Hodgkins disease?
Yes
No
Disease of the kidney, stomach, liver, pancreas, or small or large intestine; or cirrhosis?
Yes
No
Diabetes or thyroid disease?
Yes
No
Disease of the lungs or respiratory system, emphysema, asthma, or shortness of breath?
Yes
No
Disease of the heart or circulatory system, heart attack, high blood pressure or angina?
Yes
No
Psychological, psychiatric or mental disorders, anxiety or depression?
Yes
No
Neurological disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, stroke/TIA, paralysis, convulsions, epilepsy, seizures or muscular dystrophy?
Yes
No
Have you been treated or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or have you tested positive for the HIV virus (as indicated by the results of the ELISA-ELISA Western blot test series)?
Yes
No
Have you received medical advice, treatment or counseling relating to alcohol or drug abuse?
Yes
No
If you answered "Yes" to any question in this section, please explain your answer(s) below:
Please list below any prescription medications that you are currently taking:
Click the plus icon to add additional medications.
Additional Information
Do you have a valid drivers license and drive at least twice per week?
Yes
No
Are you employed outside of the home or do you participate in any volunteer activities or organizations at least 8 hours per week?
Yes
No
Have you used tobacco products within the past 12 months?
Yes
No
Additional Comments
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