Long Term Care Insurance Form

First Name *

Last Name *

Marital Status

Address

City

State

Zip

Email *

Phone *

Best day to contact

Best time to contact

Date of Birth

Gender

Male

Female

Weight

Height

Tobacco/Nicotine Use

Have you ever been treated for any of the following: (Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar health conditions?)

Yes

No

Have any of your immediate family members (parents or siblings) had: cancer, heart disease, stroke or an aneurism prior to the age of 60?

Yes

No

Have you been convicted in reckless driving or driving under influence of alcohol or drugs in the last 5 years?

Yes

No

Please list any medications currently prescribed and any health history

Coverage Amount

Coverage Length