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Agent Information:
Name:
Email:
Phone:
Date:
Jan
Feb
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Apr
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Jun
Jul
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2009
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2012
State:
Proposed Insured Information:
Name:
Male:
Female:
DOB:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Smoker?
Yes:
No:
Occupation:
Income: $
Specific Job Duties:
Is proposed insured an executive, manager or supervisor?
Yes:
No:
Number of years in position:
Number of employees managed/supervised:
Line of business:
Does proposed insured have current coverage in force?
Yes:
No:
Individual monthly amount:
$
Group - Monthly max benefit:
$
Coverage to remain in force?
Yes:
No:
Quote Information:
Monthly Benefit:
$
State of Issue:
Elimination Period (Days):
60
90
180
360
730
Benefit Period:
2 Years
5 Years
To Age 65
Lifetime (if available)
Benefit Options:
COLA 3%
COLA 6%
Social Security Rider
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):
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