516-822-8589 or toll free 877-926-8582

 

Application On Line for Long Term Care Insurance Coverage. This is not a company specific application and is used only for purposes of prescreening applicants for eligibility and suitability. In most cases with most companies a face to face interview is required at age 70 or older..

 

About You
Last Name

First Name

Middle Initial

Height
Weight
Sex
Birth Date
Age Last Birthday
Address
City
State
Zip
Billing Address if different
Day Phone Number
Best time to call
Evening Phone Number
Best time to call
Social Security Number
Marital Status
Will your spouse be applying for coverage also?

Your Personal Long Term Care Program:

Company:
Maximum Daily Facility Benefit: ($ per day)
Benefit Period:
Home Health Care Amount:
Elimination Period:
Inflation Option:
Non-forfeiture:
Payment Option:
Tax Qualification:
Do You qualify for an Affinity Group Discount

Eligibility Questions:

Please read the following questions carefully.

  Do you require assistance or supervision or are you limited in any way in performing the following daily activities:  bathing, dressing, toileting, meal preparation, housekeeping, eating, managing medications, mobility?

  Have you ever been diagnosed or treated by a physician for HIV infection or as having AIDS Related Complex (ARC), or Acquired Immune Deficiency (AIDS)?

During the past 5 YEARS, have you been diagnosed or treated by a member of the Medical Profession, Neuro-psychologist, Psychologist or Health Care Practitioner for any of the following conditions?

Alcoholism or Drug Abuse
ALS(Lou Gehrig's Disease)
Alzheimer's Disease
Aneurysm (Unoperated)
Arthritis treated with Steroids or Gold
Cerebral Vascular Disease
Cirrhosis of the Liver
Dementia
Diabetes with Insulin   (# Units Daily - )
Emphysema or COPD - with treatment
Huntington's Disease
Kidney Failure
Memory Loss (recurring)
Multiple Sclerosis
Osteoporosis with fracture
Parkinson's Disease
Stroke
Multiple Transient Isohemic Attacks (TIA's)
Your Medical History:

  Do you now, or have you in the past 5 years, used tobacco products?

Current Medications:

Please list all medications/dosages prescribed to you in the last 12 MONTHS and indicate the prescribing physician:

Medication Dosage Physician

Your Physician(s)

Please list the name and address of your Primary Physician and any other Medical Professional you have seen in the past 5 YEARS (including Physicians, Specialists, Physical Therapists, Psychologists, Neuro-psychiatrists, Health Care Practitioners).

(a) Primary Physician Name and address
Date Last Seen: Condition:
(b) Physician Name and address
Date Last Seen: Condition:
(c) Physician Name and Address:
Date Last Seen: Condition:

  Do you plan to travel or reside outside the United States for any period of time extending beyond one (1) year?

  Do you now have in force, or are you applying for, any other long term care, nursing home or home health care policy, rider or certificate (including a health care service contract or a health maintenance organization contract)?

  Other than the above, did you have a long term care policy, rider or certificate in force during the last 12 MONTHS?

If your spouse is applying for coverage, continue below, if not, please click on page down to click submit button.
About Your Spouse
Last Name
First Name
Middle Initial
Height
Weight
Sex
Birth Date
Age Last Birthday
Social Security Number

Your Spouse's Personal Long Term Care Program:

Same as Client if available

Which Company are you interested in applying to:

Maximum Daily Facility Benefit:

($ per day)

Benefit Period:

Home Health Care Amount:

Elimination Period:

Inflation Option:

Non-forfeiture:

Payment Option:

Tax Qualification:

Eligibility Questions:

Please read the following questions carefully.

  Do you require assistance or supervision or are you limited in any way in performing the following daily activities:  bathing, dressing, toileting, meal preparation, housekeeping, eating, managing medications, mobility?

  Have you ever been diagnosed or treated by a physician for HIV infection or as having AIDS Related Complex (ARC), or Acquired Immune Deficiency (AIDS)?

During the past 5 YEARS, have you been diagnosed or treated by a member of the Medical Profession, Neuro-psychologist, Psychologist or Health Care Practitioner for any of the following conditions?

Alcoholism or Drug Abuse
ALS(Lou Gehrig's Disease)
Alzheimer's Disease
Aneurysm (Unoperated)
Arthritis treated with Steroids or Gold
Cerebral Vascular Disease
Cirrhosis of the Liver
Dementia
Diabetes with Insulin   (# Units Daily - )
Emphysema or COPD - with treatment
Huntington's Disease
Kidney Failure
Memory Loss (recurring)
Multiple Sclerosis
Osteoporosis with fracture
Parkinson's Disease
Stroke
Multiple Transient Isohemic Attacks (TIA's)

Your Medical History:

  Do you now, or have you in the past 5 years, used tobacco products?

Current Medications:
Please list all medications/dosages prescribed to you in the last 12 MONTHS and indicate the prescribing physician:
Medication Dosage Physician

Your Physician(s)

Please list the name and address of your Primary Physician and any other Medical Professional you have seen in the past 5 YEARS (including Physicians, Specialists, Physical Therapists, Psychologists, Neuro-psychiatrists, Health Care Practitioners).

(a) Primary Physician Name and address

Date Last Seen: Condition:

(b) Physician Name and address

Date Last Seen: Condition:

(c) Physician Name and Address:

Date Last Seen: Condition:

  Do you plan to travel or reside outside the United States for any period of time extending beyond one (1) year?

  Do you now have in force, or are you applying for, any other long term care, nursing home or home health care policy, rider or certificate (including a health care service contract or a health maintenance organization contract)?

  Other than the above, did you have a long term care policy, rider or certificate in force during the last 12 MONTHS?



HomePage