We utilize the following companies for our clients Long Term Care Insurance
needs:
BlueCross BlueShield C.N.A. CNA,
through its member companies, is one of the country's top long-term care
insurance providers. They pioneered long-term care insurance in 1965, so they
have
the
experience to meet your long-term needs.
Allianz A++ rating by A.M. Best (superior) G.E. Financial A- rating by A.M.
Best
Mass Mutual AAA rating by Standard & Poor's and Fitch,
A++ rating by A.M. Best
Are you interested in applying for Long Term Care Insurance?
Please take a few moments to answer the following questions:
First Name:
Last Name:
Sex:
Male
Female
Age:
Birth date:
Address:
City:
State:
If you live outside Nebraska:
We are sorry that we are unable to service customers outside of Nebraska at this time.
Please send us an email
letting
us know of your desire to obtain a policy through our company, and we will begin
licensing procedures for your state of residence.
Zip:
Telephone:
--
Email Address:
Name of Company whose policy you are applying for:
1. During the past 24 months have you:
a. needed assistance or supervision for everyday
activities such as cooking, dressing, eating, housekeeping,
bathing, toileting, transferring, shopping or walking?
No Yes
b. been confined to a bed; or used a wheelchair,
walker, braces, or cane?
No Yes
c. received kidney dialysis, used oxygen equipment
or a catheter?
No Yes
d. received home health care services such as
homemaker services, physical or speech therapy, or other
rehabilitative therapy?
No
Yes
e. experienced confusion, forgetfulness or memory
loss, dizziness, fainting, weakness or fatigue, unstable gait, or
loss of bladder or bowel control?
No
Yes
f. been confined to a hospital, nursing facility,
assisted living facility, or home for the aged?
No
Yes
g. received disability benefits?
No
Yes
2. During the past 10 years, have you
been medically diagnosed with or treated for:
a. AIDS or positive HIV status
No Yes
b. Alzheimer's Disease or dementia
No
Yes
c. Amyotrophic Lateral Sclerosis
No Yes
d. Multiple Sclerosis
No Yes
e. Muscular Dystrophy
No Yes
f. Myasthenia Gravis
No
Yes
g. Organic Brain Syndrome
No Yes
h. Parkinson's Disease or Parkinsonism
No
Yes
3. During the past 10 years, have you
been medically advised or treated for:
a. abnormal blood pressure
No Yes
b. heart or cirulatory disorder
No
Yes
c. diabetes
No Yes
d. asthma, emphysema or other chronic respiratory
disorder
No Yes
e. cancer; internal or melanoma
No Yes
f. skin cancer other than melanoma
No
Yes
g. stroke or TIA (transient ischemic attack)
No Yes
h. amnesia
No Yes
i. paralysis
No
Yes
j. any form of neurological disorder
No
Yes
k. cirrhosis of the liver
No
Yes
l. alcohol or drug dependency or abuse
No
Yes
m. arthritis or osteoporosis
No
Yes
n. depression or other psychiatric disorder
No
Yes
o. seizures or other brain disorder
No Yes
p. kidney, prostate, breast or other
genito-urinary
disorder
No Yes
4. Have you consulted or been recommended to
consult with any medical specialist(s) in the last 2 years? No
Yes
If "yes", please provide the name and
specialty of the M.D. and the condition for which you were
treated.
5. In the past 12
months have you:
a. smoked cigarettes?
No Yes
b. been declined by another company for a policy
providing nursing home or home health care coverage?
No Yes
c. consulted a physician for a checkup?
No Yes
d. If "yes" above, any abnormal
findings?
No
Yes
e. consulted a physician for any other reason not
previously noted in this application?
No
Yes
f. taken prescription medication? If yes,
please list :
No
Yes
If you answered "Yes" to any of the
above questions, provide full details below.
Question # Date From
Date To
Describe Condition, Treatment and Medication
Prescribed
Name and Address of Doctor or Care Facility:
Question # Date From
Date To
Describe Condition, Treatment and Medication
Prescribed
Name and Address of Doctor or Care Facility:
Question # Date From
Date To
Describe Condition, Treatment and Medication
Prescribed
Name and Address of Doctor or Care Facility:
Question # Date From
Date To
Describe Condition, Treatment and Medication
Prescribed
Name and Address of Doctor or Care Facility:
Question # Date From
Date To
Describe Condition, Treatment and Medication
Prescribed
Name and Address of Doctor or Care Facility:
Additional Information:
1. Is any person or institution authorized
to act on your behalf due to any mental or physical disability
that you now have or have had in the past?
No
Yes
2. With whom do you currently
live?
Spouse
Family Alone
Other
3. Type of residence?
House or Condominium
ApartmentRetirement
Community Other
4. Are you actively at work?
Yes No
If "Yes," hours per week:
5. Occupation:
If retired, date of retirement:
6. Are you eligible for an approved or
pending Endorsed Group discount?
Yes
No If "Yes," Group ID Code or Name:
