Long Term Care Quote Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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Alternate Phone Number
Optional
Additional Information
Date of Birth
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/ /
E-Mail Address
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Gender
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Height
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Weight
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Tobacco Used?
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How did you hear about us?
Optional
Have you ever been declined or rated?
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Type of Physician - Date Last Consulted - Reason/Results
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Chest pain, heart murmur, high blood pressure, stroke, irregular heart beat, or other disease or disorder to the heart or arteries?
Optional

Have you ever had any type of coronary or vascular surgery?
Optional
Diabetes or disease of any gland?
Optional

A1C level
Optional
Mental or emotional disorder, nervous breakdown, convulsions, epilepsy, paralysis or any other disorder of the brain or nervous system?
Optional

Arthritis, gout, or any bone, joint, muscle, or skin disorder?
Optional

Do you have any type of respiratory disorder requiring ongoing use of oxygen or inhaler and/or breathing difficulty that limits your ability to walk/climb ONE flight of stairs?
Optional

Cirrhosis, hepatitis, ulcer, colitis, diverticulitis, or any disorder of the liver or intestines?
Optional

Prostate or testicular disease/high PSA, disease of the uterus, ovaries, or breast?
Optional

Anemia, leukemia, clotting disorder, platelet disorders, infections or sources of blood loss?
Optional

Do you have a history of ANY cancer (including skin cancer such as melanoma)?
Optional

An operation or admission to a health care facility for observation, treatment of any illness or diagnostic tests, including treadmill stress test for insurance within the last 5 years?
Optional

Disorder of the urinary tract or kidneys, sugar, albumin, or blood in urine?
Optional

Have you been diagnosed with Alzheimer's Disease, dementia or memory loss or do you take any medication for memory enhancement, such as Aricept or Namenda?
Optional

Do you require assistance with any activities of daily living, such as walking, bathing, grooming, and/or getting dressed?
Optional

Date Diagnosed(s) Condition - Details
Optional
List all Current Medications & Dosages
Optional
Additional Comments
Optional
Submission Validation
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Important Notice:
We will not resell your information to any third-party.

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