Long-Term Care Insurance Prequalification Questionnaire

Long-Term Care Insurance Prequalification Questionnaire

To help us find the best Long-Term Care insurance options for you and to make the formal application process as smooth and efficient as possible, we kindly ask you to complete this initial information form.

Gathering these details upfront allows us to better understand your needs and circumstances, which helps streamline the overall process. Please take your time to answer thoroughly and accurately. We appreciate you taking this important first step!

Accuracy Statement

"To the best of my knowledge and belief, the answers to the following questions are true, complete, and correctly recorded. I understand that incorrect or incomplete information could affect the underwriting decision or the validity of any insurance issued."

Section 1: Applicant Information

Current Address

Section 2: Lifestyle

Tobacco/Nicotine/Marijuana Use

Alcohol Consumption

Drug Use

Section 3: General Health & Insurance History

Section 4: Medications

Please list all medications (prescription and over-the-counter), including medical marijuana or THC, supplements, and vitamins you have taken or been prescribed in the last 12 months.

Section 5: Medical History & Conditions

Please indicate if you have EVER been diagnosed, treated, or consulted with a member of the medical profession for any of the following conditions. For any "Yes" answers in a table, please provide details in the text area at the bottom of that table. Details should include: Approximate date of onset/diagnosis, specific diagnosis (if known), treatments received or currently undergoing, current status, and name of treating physician/facility (optional).

Section 6: Medical Procedures, Tests & Follow-ups

Section 7: Family Medical History

Please provide the following details concerning your biological family history (parents and siblings only).

Section 8: Client Goals & Expectations (Optional)

Section 9: Attestation & Signature

By submitting this form, I affirm that the information provided in this questionnaire is true, complete, and accurate to the best of my knowledge and belief. I understand that this information will be used to assess my prequalification for Long-Term Care Insurance and that any misrepresentation may affect coverage.

Long-Term Care Insurance Prequalification Questionnaire

Long-Term Care Insurance Prequalification Questionnaire

To help us find the best Long-Term Care insurance options for you and to make the formal application process as smooth and efficient as possible, we kindly ask you to complete this initial information form.

Gathering these details upfront allows us to better understand your needs and circumstances, which helps streamline the overall process. Please take your time to answer thoroughly and accurately. We appreciate you taking this important first step!

Accuracy Statement

"To the best of my knowledge and belief, the answers to the following questions are true, complete, and correctly recorded. I understand that incorrect or incomplete information could affect the underwriting decision or the validity of any insurance issued."