Easily fill out the form below and I will contact you regarding your quote for Long-Term Care.

Analysis Request
Name:
E-mail:
Telephone:	ex. 480-555-5555
Address:
City:
State:
Zip Code:
Date of Birth	ex. 1-2-1968
Spouse Name
Spouse DOB	ex. 1-2-1968

What Role Will Your Children Play in the Care Giving Process?
Do you have any children?	Yes No
If yes, how many?	0 1 2 3 4 5
Have you had a discussion with your children about how long term care services would be provided and paid for?	Yes No
How involved do you want your children to be with the care giving process?	Not At All Partially Fully
Would your children be willing to assist you with any of your physical or financial demands?	Yes No
Do your children live in the same state you do?	Yes No
If not, would this effect their ability to participate in assisting with your care?	Yes No Somewhat
Will your children's job effect their ability to participate in providing care?	Yes No Somewhat

Personal Experience
What prompted you to start seeking information about Long Term Care insurance?
Do you know anyone who has ever needed care in a nursing home, assisted living facility or at home?	Yes No
What was the effect on their family during this time of need?
What effect did it have on them financially and emotionally?
How was the care paid for?	Savings/Retirement Current Income Medicaid/Welfare
Do you feel you are adequately prepared, if you found yourself in a position where you needed care tomorrow?	Yes No
If you were faced with a long-term care stay at $49,000.00 per year, where would the funds come from to pay for it?	Savings/Retirement Current Income Medicaid/Welfare
If you needed care tomorrow, would you rather receive that care in a facility or at home?	Home Facility

Medicare
Are you aware of what Medicare will and will not cover in regards to long term care?	Yes No
Do you know what requirements must be met before you can qualify for any coverage under the Medicare system?	Yes No

Medical Information
Husband	Wife
Tobacco Use: Yes No Quit Please Answer	Tobacco Use: Yes No Quit Please Answer
Height: xxxx	xx.xxHeight:
Weight: xxxx	xxxxWeight: x
List all hospital stays or serious illness or injury within the past ten years. Hepatitis, Heart Attack, Stroke, TIA, Diabetes, High Blood Pressure, etc.
Have you had any type of cancer in the past five years? If yes, explain type, treatment, and current prognosis
What prescription medications are you currently taking?
Medication Taken:	Medication Taken:
Condition It's For:	Condition It's For:
Medication Taken:	Medication Taken:
Condition It's For:	Condition It's For:
Medication Taken:	Medication Taken:
Condition It's For:	Condition It's For:
Medication Taken:	Medication Taken:
Condition It's For:	Condition It's For:

Final Summary
What is your primary objective in considering Long Term Care insurance?
If you were faced with a long-term care stay tomorrow at $50,000 per year, how many years would you be able to last?	Less than 1 Year 1 Year 2 Years 3 Years 4 Years 5 Years Never run out of money
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