CONSULTANTS INSURANCE SERVICES
Specializing in Long Term Care Solutions

LTC INSURANCE QUALIFYING QUESTIONNAIRE
Copy/Paste to an e-mail to fill out

1) Are you currently being treated for any health condition and/or taking prescription medication to control any condition?
If "yes": What is the condition? How long have you had it? How is it being treated?

2) Have you ever suffered from a stroke of any type?
If "yes": Major or minor? When did it occur?

3) Have you ever been treated for any type of cancer?
If "yes": Where was the cancer? When was it diagnosed? What stage was it? When did treatment end? Did the cancer spread or recur?

4) Have you had any heart conditions or serious arthritis issues?
If "yes": Please provide details.

5) Are you diabetic?
If "yes": How is it being controlled? How long have you had this condition? What are your usual blood sugar readings and A1C levels?

The average cost of long term care is approximately $6000-$7500 a month, or $72,000-$90,000 a year (cost of care, not the cost of insurance!).

If you were to need care tomorrow, do you have enough liquid assets (savings, stocks, mutual funds, etc.) to pay out-of-pocket for at least one to two years without having to tap into home equity?

What prompted you to look into long term care protection at this time?

What concerns do you have about the need for long term care, whether that need be now, or in the future?

How much coverage are you looking for in terms of daily benefit amounts, benefit years and elimination period?

Approximately how much would you be comfortable spending on premiums for this type of coverage?

If you would complete the above questionnaire and e-mail it to us along with your contact information, we will be able to make the proper evaluation of your long term care insurance health and rating options. Thank you in advance for your answers! The information will be kept confidential and will only be used to determine eligibility for coverage, make proper recommendations, and help design appropriate coverage

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