Individual Long-Term Care Individual Long-Term Care Individual Long-Term Care General InformationFull Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Current LTC Insurance InformationCarrier / Company Name (Not Agency) Policy Expiration Date: MM slash DD slash YYYY Premium Amt ($): Years Insured: Please give a brief description of your current LTC insurance planCoverage OptionsType of Coverage New Coverage Additional Coverage Replacement Waiting Period- - - -30 Days60 Days90 Days180 Days365 DaysDaily Benefit Amount- - - -708090100110120130140150160170180190200210220230240250Benefit Period- - - -2 Years3 Years4 Years5 YearsLifetimeInflation ProtectionNoneSimpleCompoundDo you want your policy to include home-health care coverage? Yes No Information About You & Your SpousePlease enter information below for all to be coveredYour InformationDate of Birth MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupation Height Weight Smoker Yes No Have you had any of the following health conditions? None Heart Cancer Diabetes HBP Spouse InformationName First Last Date of Birth MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupation Height Weight Smoker Yes No Have you had any of the following health conditions? None Heart Cancer Diabetes HBP Briefly describe any medical events in the past 10 years that have required hospitalization or surgery for either you or your spouseFinal Questions/CommentsHow did you hear about us? Currently Insured Google Yellow Pages Saw Our Advertisements Yelp Referred by Family or Friend Other Comments / RemarksConsent By filling out this form, I authorize Steve Hom Insurance to communicate with me via text messagingBy filling out this form, I authorize Steve Hom Insurance to communicate with me via text messaging
