Long-Term Care Worksheet

Agent Information:
Name: Phone: Email:

Client Information:
Name:  
Male: Female:
 
DOB:      
  Height:     feet   inches   Weight: lbs.
Married - Spouse Applying

Name of Spouse:  
Male: Female:
 
DOB:    
  Height:     feet   inches   Weight: lbs.

Married - Spouse Not Applying

Reason for not applying:

Single
Smoking: Has any person applying used tobacco/nicotine within the past 5 years?
Yes No
Driving: Have you driven an automobile at least 5 times during the past month?
Yes No

Benefit Selection:
Maximum Daily Facility Benefit: $
    [Min. $50/day; $10 increments; Max. $300/day]
Benefit Period:
  2 Years (730x)
  3 Years (1095x)
  3 Years (1095x)
  4-years (1460x)
  5-years (1825x)
  Lifetime (unlimited)

Maximum Lifetime Benefit:   $
    [Multiply Daily Facility Benefit amount by Benefit Period chosen.]

Maximum Home and Community-Based Care Benefit:
  50% [Maximum Daily Facility Benefit may not be less than $100.]
  75% [Maximum Daily Facility Benefit may not be less than $70.]
  100% [Maximum Daily Facility Benefit may not be less than $60.]
Elimiation Period:
  0 Days [Not available for ages 80+.]
  30 Days  
  60 Days  
  90 Days  
  180 Days [Not available with 2-year benefit period.]
  365 Days [Not available with 2-year benefit period.]
Inflation Benefit:
  None
  5% Simple
  5% Compound
  Deferred Purchase Option
Premium Payment Mode: Premium Payment Options:
 
(more than 1 item may be selected)
  BOM Monthly   Continuous Pay  
  Quarterly   10-Year Pay [may not be available]
  Semi-annual   20-Year Pay [may not be available]
  Annual   Single Pay [may not be available]
BEGIN QUESTIONNAIRE
If any part of Questions 1 through 3 is answered “Yes”, a traditional LTC policy cannot be issued.

1) Are you currently receiving disability from work, or on Social Security, Disability,
Welfare, Medi-Cal and/or Medicaid?
Yes No


2) Have you ever been diagnosed as having or been treated by a member of the medical profession for any of the following conditions?
 
  a) Acquired Immune Deficiency Syndrome (AIDS) Yes No
b) AIDS Related Complex (ARC) Yes No
  c) Alzheimer’s Disease Yes No
  d) Amputation Due to Disease Yes No
  e) Amyotrophic Lateral Sclerosis (Lou Gehrig’s Diesease) Yes No
  f) Chronic Hepatitis Yes No
  g) Cirrhosis of the Liver Yes No
  h) Dementia or Organic Brain Syndrome Yes No
  i) Diabetes with Stroke/TIA Yes No
  j) Hydrocephalus Yes No
  k) Multiple Falls Yes No
  l) Multiple Sclerosis Yes No
  m) Muscular Dystrophy Yes No
  n) Myasthenia Gravis Yes No
  o) Osteoporosis with Compression Fracture Yes No
  p) Paraplegia or Quadriplegia Yes No
  q) Parkinson’s Disease Yes No
  r) Polymyositis Yes No
  s) Scleroderma Yes No
  t) Senility Yes No
  u) Stroke or TIA in past 24 months Yes No
  v) Strokes (more than 1 CVA/TIA) Yes No


3) a. Do you have any impairments, whether mental or physical, for which you need or receive assistance or supervision in performing everyday living activities (such as walking, eating, dressing, or personal hygiene including toileting or bathing?)
Yes No
  b. Do you CURRENTLY use: a catheter, dialysis, oxygen equipment, a quad or three pronged cane, respirator, walker, wheelchair, braces, crutches, motorized scooter or chair lift?
Yes No


4) In the last 5 years, have you been diagnosed as having or been treated by a member of the medical
profession for any of the following conditions?
 
  a) Alcoholism Yes No
b) Cancer Yes No
  c) Chronic Obstructive Pulmonary Disease Yes No
  d) Depression Yes No
  e) Diabetes Yes No
  f) Drug Addiction Yes No
  g) Epilepsy Yes No
  h) Heart Attack Yes No
  i) Hodgkin’s Disease Yes No
  j) Kidney Disorder Yes No
  k) Leukemia Yes No
  l) Osteoporosis Yes No
  m) Paralysis Yes No
  n) Rheumatoid Arthritis Yes No
  o) Memory Loss Yes No
  p) Stroke Yes No
  q) Transient Ischemic Attack Yes No


5) Within the past 2 years, have you been confined in a hospital or nursing facility or
been recommended by a member of the medical profession for admission to same?
Yes No


6) Within the past 5 years, have you been treated or diagnosed by a member of the
medical profession as having had any other illness, medical or surgical treatment
or check up?
Yes No


7) Do you currently use a cane (including occasional use for balance)?
Yes No


8) Are you currently taking any prescription drugs or medications?
Yes No
  Please list all medication(s):
 

 
Type the letters seen above into the box: