Long Term Care Our process is transparentFor Help Call 1-(248)-856-9000 GENERAL INFORMATION Fields marked (*) are mandatory NAME ADDRESS CITY STATE Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP CODE DAY PHONE NIGHT PHONE E-MAIL ADDRESS SOC.SEC. # (OPTIONAL) DATE OF BIRTH AGE SEX Male Female HEIGHT (FT./IN.) WEIGHT MATRIAL STATUS Married Single IF MARRIED, WILL SUPOUSE ALSO APPLIY FOR COVERAGE? Yes No NOTE: If 'YES', your spouse will need to complete a separate form. CURRENT/PREVIOUS INSURANCE INFORMATION Fields marked (*) are mandatory DO YOU CURRENTLY HAVE ANOTHER LONG-TERM CARE INSURANCE POLICY, RIDER OR CERTIFICATE (INCLUDING HEALTH CARE SERVICE CONTRACT OR HEALTH MAINTENANCE ORGA Yes No DID YOU PREVIOUSLY HAVE ANOTHER LONG-TERM CARE INSURANCE POLICY, RIDER OR CERTIFICATE IN FORCE DURING THE LAST 12 MONTHS? Yes No IF SO, WHEN DID IT LAPSE ARE YOU COVERED BY A STATE ASSISTANCE PROGRAM (MEDICAID)? Yes No DO YOU INTEND TO REPLACE ANY OF YOUR MEDICAL OR HEALTH INSURANCE COVERAGE WITH THIS POLICY, RIDER OR CERTIFICATE? Yes No ARE YOU NOW RECEIVING LONG-TERM CARE OR DISABILITY BENEFITS? Yes No HAVE YOU EVER BEEN DENIED COVERAGE FOR MEDICAL INSURANCE, DISABILITY INSURANCE, LONG-TERM CARE INSURANCE, NURSING HOME INSURANCE, OR LIFE INSURANCE? Yes No IF 'YES', PLEASE EXPLAIN ACTIVITIES INFORMATION HAVE YOU BEEN CONFINED TO A HOSPITAL IN THE LAST 12 MONTHS? Yes No HAS A PHYSICIAN RECOMMENDED IN THE PAST 24 MONTHS THAT YOU BE HOSPITALIZED OR CONFINED TO A NURSING FACILITY, OR THAT YOU HAVE A SURGICAL PROCEDURE? Yes No HAVE YOU CONSULTED WITH A PHYSICIAN IN THE LAST 12 MONTHS FOR LOSS OF APPETITE, FALLING, UNSTABLE GAIT, BLADDER OR BOWEL CONTROL, DIZZINESS OR VISION Yes No DO YOU NEED THE HELP OR SUPERVISION OF ANOTHER INDIVIDUAL TO PERFORM YOUR EVERYDAY LIVING ACTIVITIES SUCH AS WALKING, DRESSING, EATING, TAKING MEDICAT Yes No DO YOU NEED THE HELP OR SUPERVISION OF ANOTHER INDIVIDUAL TO PERFORM THE INDEPENDENT ACTIVITIES OF DAILY LIVING SUCH AS HANDLING YOUR FINANCES, DOING Yes No DO YOU USE ANY ASSISTIVE DEVICES SUCH AS A WALKER, WHEELCHAIR, CRUTCHES, CANE, GRAB BARS OR ANY PRESCRIBED MEDICAL DEVICE OR APPLICANCE? Yes No IF 'YES', PLEASE EXPLAIN MEDICAL INFORMATION If you answer 'Yes' to any of the questions below, please use the text box at the end of this section to explain your answer. In the past 5 years have you ever had, been told by a physician you had, or been treated for: -OSTEO ARTHRITIS, OSTEOPOROSIS, AMPUTATION, BONE OR JOINT DISEASE, RHEUMATOID ARTHRITIS, OR SPINAL STENOSIS? Yes No -INTERNAL CANCER, TUMOR, LEUKEMIA, LYMPHOMA, ORHODGKINS DISEASE? Yes No -DISEASE OF THE KIDNEY, STOMACH, LIVER, PANCREAS, OR SMALL OR LARGE INTESTINE; OR CIRRHOSIS? Yes No -DIABETES OR THYROID DISEASE? Yes No -DISEASE OF THE LUNGS OR RESPIRATORY SYSTEM, EMPHYSEMA, ASTHMA, OR SHORTNESS OF BREATH? Yes No -DISEASE OF THE HEART OR CIRCULATORY SYSTEM, HEART ATTACK, HIGH BLOOD PRESSURE OR ANGINA? Yes No -PSYCHOLOGICAL, PSYCHIATRIC OR MENTAL DISORDERS, ANXIETY OR DEPRESSION? Yes No -NEUROLOGICAL DISORDERS INCLUDING PARKINSON'S DISEASE, MULTIPLE SCLEROSIS, ALZHEIMER'S DISEASE, STROKE/TIA, PARALYSIS, CONVULSIONS, EPILEPSY, SEIZURE Yes No -HAVE YOU BEEN TREATED OR DIAGNOSED BY A MEMBER OF THE MEDICAL PROFESSION AS HAVING ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) OR HAVE YOU TESTED POS Yes No -HAVE YOU RECEIVED MEDICAL ADVICE, TREATMENT OR COUNSELING RELATING TO ALCOHOL OR DRUG ABUSE? Yes No IF YOU ANSWERED 'YES' TO ANY QUESTION IN THIS SECTION, PLEASE EXPLAIN YOUR ANSWER(S) MEDICAL INFORMATION PLEASE LIST ANY PRESCRIPTION MEDICATIONS THAT YOU ARE CURRENTLY TAKING ADDITIONAL INFORMATION DO YOU HAVE A VALID DRIVERS LICENSE AND DRIVE AT LEAST TWICE PER WEEK? Yes No ARE YOU EMPLOYED OUTSIDE OF THE HOME OR DO YOU PARTICIPATE IN ANY VOLUNTEER ACTIVITIES OR ORGANIZATIONS AT LEAST 8 HOURS PER WEEK? Yes No HAVE YOU USED TOBACCO PRODUCTS WITHIN THE PAST 12 MONTHS? Yes No PLEASE GIVE ANY ADDITIONAL COMMENTS YOU FEEL APPROPRIATE FOR THIS QUOTATION Send