PRE-PLANNING TOOL

Long-Term Care Insurance

Please see the uninsurable medication and conditions list before continuing. Please note certain drop down selections will open additional fields. To proceed to the health pre-screen, select the health dropdown and choose “I would like to do a pre-screen”. If you have any questions regarding this form, please contact our office at (800) 255-1932.

Uninsurable Medications

*Generic versions also uninsurable

Antabuse®
Aricept®
Artane®
Avonex®
Azilect
Betaseron®
Campral®
Cogentin®
Cognex®
Comtan®
Copaxone®
Depade®
Donepezil
Eldepryl®
Exelon®
Fentanyl
Galantamine
Hydergine®
Interferon®
Larodope/L-Dopa
Lucemyra
Memantine
Methadone
Mirapex®
Namenda®
Namzaric®
Parlodel®
Permax®
Razadyne®
Reminyl®
ReVia®
Rivastigmine®
Sinemet®
Suboxone®
Symmetrel®
Vivitrol®

Uninsurable Conditions

Activity of daily living deficits (need help with any of the ADL’s)
Alcoholism (active)
Alzheimer’s/Dementia
Amyotrophic Lateral Sclerosis (ALS)
Balance disorder/ Gait impairment
Cerebral palsy
Cirrhosis
Depression (severe or hospitalized in the last 5 years)
Down syndrome
Drug addiction/illicit drug use (within last ten years)
HIV positive
Huntington’s disease
Macular degeneration (progressive/wet)
Memory loss
Mental retardation
Multiple myeloma
Multiple sclerosis (MS)
Muscular dystrophy
Organ transplant (except kidney)
Organic brain syndrome
Osteoporosis with compression fracture
Paralysis (paraplegia/quadriplegia)
Parkinson’s disease
Pregnancy (current)
Stroke (multiple or residual affects)
Surgery pending (will review after)
Ventricular tachycardia

Contact Information
Name*
Email*
Phone
Relationship to Insured*
How would you like us to reach out?
- Please do not contact my client at this time and send all information to me.
- Please reach out to my client directly.
Client Email Address
Client Phone Number
Please explain*
Proposed Insured Information
The "first person" is the proposed policyholder. If they are married and are seeking a joint policy, please complete the applicable information in the "second person" column for their partner.
FIRST PERSON
SECOND PERSON
Name
Name
Birth Date OR Age*
Birth Date OR Age
Gender*
Gender
State of Residence*
Health
Health
Health Pre-Screen
FIRST PERSON
SECOND PERSON
Height
Height
Weight
Weight
Smoker?
Smoker?
Date of most recent doctor visit/reason for visit:
Date of most recent doctor visit/reason for visit:
Medications, dosage and reason for taking them and for how long? Any pain medications or treatments, shots? Date of last one?
Leave blank if not applicable
Leave blank if not applicable
Heart or Lung Issues? Bypass? COPD When?
Leave blank if not applicable
Leave blank if not applicable
Bone or Joint Issues? Osteoporosis or Osteopenia? Last Bone Density Test?
Leave blank if not applicable
Leave blank if not applicable
Joint Replacements? When?
Leave blank if not applicable
Leave blank if not applicable
Cancer of any kind? Stage? Metastasis? Date of last treatment
Leave blank if not applicable
Leave blank if not applicable
Diabetes? A1C Score? Insulin? How many units?
Leave blank if not applicable
Leave blank if not applicable
Arthritis - Rheumatoid? Osteo?
Leave blank if not applicable
Leave blank if not applicable
Any planned or suggested surgeries?
Leave blank if not applicable
Leave blank if not applicable
Sleep Apnea? Are you compliant with a device? For how long?
Leave blank if not applicable
Leave blank if not applicable
Vertigo? Last episode? How often?
Leave blank if not applicable
Leave blank if not applicable
Are you collecting disability insurance? Private or Social Security?
Leave blank if not applicable
Leave blank if not applicable
Do you have a handicapped license plate or sticker?
- Yes
- No
- Yes
- No
Have you been declined previously for LTCi?
- Yes
- No
- Yes
- No
Any other health issues we should know about?
Leave blank if not applicable
Leave blank if not applicable
Do you know the exact amount and what type of coverage you are looking for?
- Yes, I would like to specify the exact benefit coverage amounts (this is uncommon).
- No, please show me the best options available based on my financial situation.
Financial Information
This information will help us determine if a long-term care insurance policy is financially suitable and will help us design a policy customized for you.
Income Information

(Gross Monthly)
FIRST PERSON
SECOND PERSON
Monthly Employment Income
Monthly Employment Income
Monthly Social Security Income
If currently receiving benefits, please type the monthly amount received. If not taking benefits, please type the projected monthly benefit amount at normal retirement age.
Monthly Social Security Income
Monthly Pension(s) Income
Monthly Pension(s) Income
Other Monthly Income
Other Monthly Income
Total Monthly Income
Total Monthly Income
Asset Information
Retirement Accounts
Total combined value of IRAs, Roth IRAs, 401(k)s, SEPs, SIMPLEs, etc.
Retirement Accounts

Annuity Information

Current Value	Capital Gain

Annuity Information

Current Value	Capital Gain

Total Value of all annuities
Total Value of all annuities
Non-Qualified Assets
Total of checking, savings, taxable investments (i.e. stocks, bonds, mutual funds, CDs). DO NOT INCLUDE retirement accounts, personal property, vehicles, illiquid assets.
Non-Qualified Assets
Additional Notes
Benefit Coverage Amounts
Please fill out the following information only if you have a specific coverage amount you would like quoted. If you would like a policy designed based on the insured's financial information, please select "No" above.
FIRST PERSON
SECOND PERSON
Monthly Benefit ($)
Please enter a number from 2000 to 12000.
Monthly Benefit ($)
Please enter a number from 2000 to 12000.
Years of Coverage
Years of Coverage
Inflation Protection
Inflation Protection
NOTE: State partnership only available for traditional policies
Type of Policy
Type of Policy
Upload Document(s)
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 305 MB.
Additional Notes
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PRE-PLANNING TOOL

Long-Term Care Insurance

Uninsurable Medications

*Generic versions also uninsurable

Uninsurable Conditions

Contact Information

Proposed Insured Information

Health Pre-Screen

Financial Information

Income Information

Asset Information

Benefit Coverage Amounts

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PRE-PLANNING TOOL

Long-Term Care Insurance

Uninsurable Medications

*Generic versions also uninsurable

Uninsurable Conditions

Contact Information

Proposed Insured Information

Health Pre-Screen

Financial Information

Income Information

Asset Information

Benefit Coverage Amounts

NOT SURE WHERE TO START?

Returning Agent?
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