LONG-TERM CARE

Name:

Address:

City:

Day Phone:

Email Address:

Date of Birth (mm/dd/yy): 

Height:

Marital Status: 

Do you currently have another Long-Term Care insurance policy, rider or certificate (including health care service contract or health maintenance organization contract)?

Did you previously have another Long-Term Care insurance policy, rider or certificate in force during the last 12 months?
If so, when did it lapse (mm/dd/yy):

Do you intend to replace any of your medical or health insurance coverage with this policy, rider or certificate?

Are you now receiving long-term care or disability benefits?

Have you ever been denied coverage for medical insurance, disability insurance, long-term care insurance, nursing home insurance, or life insurance?

Have you been confined to a hospital in the last 12 months?

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?

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?

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?

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?

Do you use any assistive devices such as a walker, wheelchair, crutches, cane, grab bars or any prescribed medical device or applicance?

--osteoarthritis, osteoporosis, amputation, bone or joint disease, rheumatoid arthritis, or spinal stenosis?

--internal cancer, tumor, leukemia, lymphoma, or Hodgkins disease?

--disease of the kidney, stomach, liver, pancreas, or small or large intestine; or cirrhosis?

--diabetes or thyroid disease?

--disease of the lungs or respiratory system, emphysema, asthma, or shortness of breath?

--disease of the heart or circulatory system, heart attack, high blood pressure or angina?

--psychological, psychiatric or mental disorders, anxiety or depression?

--neurological disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, stroke/TIA, paralysis, convulsions, epilepsy, seizures or muscular dystrophy?

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)?

Have you received medical advice, treatment or counseling relating to alcohol or drug abuse?

Do you have a valid drivers license and drive at least twice per week?

Are you employed outside of the home or do you participate in any volunteer activities or organizations at least 8 hours per week?

Have you used tobacco products within the past 12 months?