Individual Long-Term Care Individual Long-Term Care Individual Long-Term Care General InformationFull Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Current LTC Insurance InformationCarrier / Company Name (Not Agency)Policy Expiration Date: Date Format: MM slash DD slash YYYY Premium Amt ($):Years Insured:Please give a brief description of your current LTC insurance planCoverage OptionsType of CoverageNew CoverageAdditional CoverageReplacementWaiting 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?YesNoInformation About You & Your SpousePlease enter information below for all to be coveredYour InformationDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupationHeightWeightSmokerYesNoHave you had any of the following health conditions? None Heart Cancer Diabetes HBP Spouse InformationName First Last Date of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleMarital StatusSingleMarriedOccupationHeightWeightSmokerYesNoHave 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 / Remarks
