Long Term Care Application

Long Term Care Insurance Application
Please enter numbers without commas
* Required Fields

First Name *		Last Name *
Home Phone	Home Fax	E-Mail

Street Address

City

State

Zip
-

Applicant's Health Information

Date of Birth: / /

Sex: M F

Smoker: Yes No

Are you currently under any nursing or home care? Yes No

Current Medications

Medication	Illness For Which Prescribed	Date Prescribed	Date Discontinued
		/	/
		/	/
		/	/

Summary of Medical History

Date of Onset/Treatment: /	Date Ended: / Still Under Treatment
Name of Condition / Illness:
Treatment Rendered (i.e. X-Ray, lab, surgery, etc):

Date of Onset/Treatment: /	Date Ended: / Still Under Treatment
Name of Condition / Illness:
Treatment Rendered (i.e. X-Ray, lab, surgery, etc):

Date of Onset/Treatment: /	Date Ended: / Still Under Treatment
Name of Condition / Illness:
Treatment Rendered (i.e. X-Ray, lab, surgery, etc):

Spouse's Health Information

First Name:

Last Name:

Date of Birth: / /

Sex: M F

Smoker: Yes No

Are you currently under any nursing or home care? Yes No

Current Medications

Medication	Illness For Which Prescribed	Date Prescribed	Date Discontinued
		/	/
		/	/
		/	/

Summary of Medical History

Date of Onset/Treatment: /	Date Ended: / Still Under Treatment
Name of Condition / Illness:
Treatment Rendered (i.e. X-Ray, lab, surgery, etc):

Date of Onset/Treatment: /	Date Ended: / Still Under Treatment
Name of Condition / Illness:
Treatment Rendered (i.e. X-Ray, lab, surgery, etc):

Date of Onset/Treatment: /	Date Ended: / Still Under Treatment
Name of Condition / Illness:
Treatment Rendered (i.e. X-Ray, lab, surgery, etc):

Coverage Information

Type of Plan: Comprehensive Nursing Facility Only Home Care Only
Daily Benifit:	Benefit Period:	Waiting Period:
Inflation Riders: None 5% Simple 5% Compound

Notes

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