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For a Free LTC Quote please fill out the form below and we will email you your quote within 24 hours!
Disclaimer: Filling out this form does not in any way guarantee coverage.
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Date of Birth
Are you covered by Medicaid (not the same as Medicare)?
Do you use a Walker, Wheelchair or Quad Cane; Hospital Bed; Oxygen, Respirator or Kidney Dialysis; or need assistance or supervision by another person in performing any of the following: Moving in/out of bed or chair, Bathing, Dressing, Eating, Toileting, Bowel/Bladder control, or Walking?
Have you been advised to: receive home care, use an adult day care facility, enter a nursing home, enter an assisted care facility, or enter any other long term care facility?
In the past 4 years have you had Cancer of the: Bone, Brain, Esophagus, Liver, Lung, Ovary, Pancreas, or Stomach?
Have you ever been diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) caused by the Human Immunodeficiency Virus (HIV) infection or other sickness or condition derived from such infection or received a positive test result from a test administered by a member of the medical profession for HIV?
Have you had, do you currently have, or have you ever been medically diagnosed as having any of the following:
ALS (Lou Gehrig’s disease)
Congestive Heart Failure (CHF) in combination with any of the following: Heart Attack or Angina; Emphysema/ Chronic Obstructive Pulmonary Disease (COPD); Angioplasty or Heart Surgery; Asthma or Chronic Bronchitis
Cirrhosis of the Liver
Diabetes under treatment with Insulin or with a history of TIA, Heart Disease, or Circulatory/Vascular Disease
Frequent or persistent forgetfulness or memory loss
Metastatic Cancer (spread from original site/location)
Multiple Sclerosis (MS)
Organic Brain Syndrome
Transient Ischemic Attack (TIA) within the past 5 years
TIA in combination with Diabetes or Heart Surgery
TIA two or more times
*PLEASE NOTE BEFORE YOU CONTINUE If you answered
to any of the questions above, we suggest that you do not submit this request. If you answered NO to every question, please continue.
In the past 5 years (10 years for cancer) have you: received medical advice or treatment; been medically diagnosed; or consulted with a health professional for any of the following conditions?
Angioplasty or Heart Surgery
Asthma or Chronic Bronchitis
Cancer (excl. Basal Cell of the Skin)
Carotid or other Arterial Surgery
Congestive Heart Failure
Diabetes not treated with Insulin
Disabling Back or Spine Condition
Epilepsy, Seizures, or Convulsions
Fainting Spells or Blacking Out
Heart Attack, Angina or Atrial Fibrillation
Immune System Disorders
Injury due to Falls or Imbalance
Joint Replacement Surgery
Other Conditions Causing Crippling or Limited Motion, or Requiring Adaptive Devices
Within the past 5 years, have you:
Used Tobacco in any form?
Required assistance with managing medications, shopping, using transportation, or housekeeping/cooking?
Received home health care; used an adult day care facility; been confined to a nursing home, assisted care facility, or other long term care facility?
Been medically advised to have surgery which has not been performed?
Received Social Security Disability Insurance benefits?
Taken any prescription medications for High Blood Pressure and/or any form of Arthritis?
In the last 2 Years, had another Long Term Care insurance application denied by us or any other company?
Within the past 3 years have you: A. Taken any prescription medications? If so, please list them below along with the mg and times taken daily.
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