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800.921.3100
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888.754.1444
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866.592.7974
Long-Term Care Worksheet
Agent Information:
Name:
Phone:
Email:
Client Information:
Name:
Male:
Female:
DOB:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Height:
feet
inches
Weight:
lbs.
Married - Spouse Applying
Name of Spouse:
Male:
Female:
DOB:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Height:
feet
inches
Weight:
lbs.
Married - Spouse Not Applying
Reason for not applying:
Single
Smoking: Has any person applying used tobacco/nicotine within the past 5 years?
Yes
No
Driving: Have you driven an automobile at least 5 times during the past month?
Yes
No
Benefit Selection:
Maximum Daily Facility Benefit:
$
[Min. $50/day; $10 increments; Max. $300/day]
Benefit Period:
2 Years (730x)
3 Years (1095x)
3 Years (1095x)
4-years (1460x)
5-years (1825x)
Lifetime (unlimited)
Maximum Lifetime Benefit:
$
[Multiply Daily Facility Benefit amount by Benefit Period chosen.]
Maximum Home and Community-Based Care Benefit:
50%
[Maximum Daily Facility Benefit may not be less than $100.]
75%
[Maximum Daily Facility Benefit may not be less than $70.]
100%
[Maximum Daily Facility Benefit may not be less than $60.]
Elimiation Period:
0 Days
[Not available for ages 80+.]
30 Days
60 Days
90 Days
180 Days
[Not available with 2-year benefit period.]
365 Days
[Not available with 2-year benefit period.]
Inflation Benefit:
None
5% Simple
5% Compound
Deferred Purchase Option
Premium Payment Mode:
Premium Payment Options:
(more than 1 item may be selected)
BOM Monthly
Continuous Pay
Quarterly
10-Year Pay
[may not be available]
Semi-annual
20-Year Pay
[may not be available]
Annual
Single Pay
[may not be available]
BEGIN QUESTIONNAIRE
If any part of Questions 1 through 3 is answered “Yes”, a traditional LTC policy cannot be issued.
1)
Are you currently receiving disability from work, or on Social Security, Disability,
Welfare, Medi-Cal and/or Medicaid?
Yes
No
2)
Have you ever been diagnosed as having or been treated by a member of the medical profession for any of the following conditions?
a) Acquired Immune Deficiency Syndrome (AIDS)
Yes
No
b) AIDS Related Complex (ARC)
Yes
No
c) Alzheimer’s Disease
Yes
No
d) Amputation Due to Disease
Yes
No
e) Amyotrophic Lateral Sclerosis (Lou Gehrig’s Diesease)
Yes
No
f) Chronic Hepatitis
Yes
No
g) Cirrhosis of the Liver
Yes
No
h) Dementia or Organic Brain Syndrome
Yes
No
i) Diabetes with Stroke/TIA
Yes
No
j) Hydrocephalus
Yes
No
k) Multiple Falls
Yes
No
l) Multiple Sclerosis
Yes
No
m) Muscular Dystrophy
Yes
No
n) Myasthenia Gravis
Yes
No
o) Osteoporosis
with
Compression Fracture
Yes
No
p) Paraplegia or Quadriplegia
Yes
No
q) Parkinson’s Disease
Yes
No
r) Polymyositis
Yes
No
s) Scleroderma
Yes
No
t) Senility
Yes
No
u) Stroke or TIA in past 24 months
Yes
No
v) Strokes (more than 1 CVA/TIA)
Yes
No
3)
a. Do you have any impairments, whether mental or physical, for which you need or receive assistance or supervision in performing everyday living activities (such as walking, eating, dressing, or personal hygiene including toileting or bathing?)
Yes
No
b. Do you CURRENTLY use: a catheter, dialysis, oxygen equipment, a quad or three pronged cane, respirator, walker, wheelchair, braces, crutches, motorized scooter or chair lift?
Yes
No
4)
In the last 5 years, have you been diagnosed as having or been treated by a member of the medical
profession for any of the following conditions?
a) Alcoholism
Yes
No
b) Cancer
Yes
No
c) Chronic Obstructive Pulmonary Disease
Yes
No
d) Depression
Yes
No
e) Diabetes
Yes
No
f) Drug Addiction
Yes
No
g) Epilepsy
Yes
No
h) Heart Attack
Yes
No
i) Hodgkin’s Disease
Yes
No
j) Kidney Disorder
Yes
No
k) Leukemia
Yes
No
l) Osteoporosis
Yes
No
m) Paralysis
Yes
No
n) Rheumatoid Arthritis
Yes
No
o) Memory Loss
Yes
No
p) Stroke
Yes
No
q) Transient Ischemic Attack
Yes
No
5)
Within the past 2 years, have you been confined in a hospital or nursing facility or
been recommended by a member of the medical profession for admission to same?
Yes
No
6)
Within the past 5 years, have you been treated or diagnosed by a member of the
medical profession as having had any other illness, medical or surgical treatment
or check up?
Yes
No
7)
Do you currently use a cane (including occasional use for balance)?
Yes
No
8)
Are you currently taking any prescription drugs or medications?
Yes
No
Please list all medication(s):
Type the letters seen above into the box:
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