Long-Term Care Insurance

Complete this form to apply for Long-Term Care Insurance.

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Policy Choices

Health Insurability Questions

If you answer “Yes” to any of the questions in this Section D, we are unable to accept this application or offer you Long-Term Care Insurance. Do not continue.
1) Are you age 65 or older and has it been more than 2 years since you have had a doctor’s visit which included a head to toe physical examination with blood work (basic metabolic chemistry panel)?
2) Do you currently use any of the following?
Quad Cane
Walker
Wheelchair
Electric Scooter
Stairlift
Hospital Bed
Nebulizer
Oxygen (including supplemental CPAP use
3) Within the past 6 months have you been confined to, used, or been advised to have, any of the following?
A Residential Care Facility
An Adult Day Care Facility
A Nursing Facility
Home Care Services
4) Do you require the assistance or supervision of another person or a device of any kind for any of the following?
Bathing
Toileting
Dressing
Eating
Medication Management
Getting in and out of a chair or bed
Your inability to control your bowel or bladder
5) Do you have Diabetes and...
take more than 50 units of insulin per day?
have peripheral neuropathy?
have numbness, tingling or decreased sensation in your feet?
have retinopathy?
have you ever had a stroke?
have you ever had a ministroke?
have you ever had a Transient Ischemic Attack (TIA)?
6) Have you ever had, been diagnosed as having, or received medical advice or medical care from a physician or health care provider for any of the following?
(a) Alzheimer’s Disease
(b) Dementia
(c) Memory Loss
(d) Mild Cognitive Impairment
(e) Organic Brain Syndrome
(f) Schizophrenia
(g) Mental Retardation
(h) Connective Tissue Disease
(j) Huntington’s Chorea
(k) Chronic Hepatitis
(l) Cirrhosis
(i) Kidney Failure or received Dialysis
(m) Hydrocephalus
(n) Multiple Myeloma
(o) Psychosis
(p) Organ Transplant
(q) Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig’s Disease)
(r) Parkinson’s Disease
(s) Systemic Lupus
(t) Multiple Sclerosis (MS)
(u) Muscular Dystrophy
(v) Myasthenia Gravis
(w) Scleroderma
(x) Paralysis
(y) Ministroke or Transient Ischemic Attack (TIA) in the past year
(z) Single episode stroke in the past 2 years
(aa) Two or more strokes or TIAs
(ab) Not fully recovered or continue to have weakness, decreased sensation or loss of function from a stroke or TIA
(ac) Cancer (except basal or squamous cell skin cancers, or stage I/A bladder, thyroid, breast or prostate cancers) in the past 2 years
(ad) Chronic Obstructive Pulmonary Disease (COPD) and have used tobacco in the past year
(ae) Emphysema and have used tobacco in the past year
(af) Chronic Bronchitis and have used tobacco in the past year
7) Have you been diagnosed or treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?
8) Do you currently qualify for payment or are you receiving payment benefits under Medicaid/Medi-Cal (not Medicare), disability income plan, workers’ compensation, Social Security disability or any federal or state disability plan?

Primary Physician Information and Medication

Applicant A

1) Provide the name, address and phone number of primary physician you have consulted within last 10 years:
2) Are you taking or have you taken any prescription medication(s) within the past 12 months, or are you currently taking any over-the-counter medication(s) on a weekly basis or more frequently?

Applicant B

1) Provide the name, address and phone number of primary physician you have consulted within last 10 years:
2) Are you taking or have you taken any prescription medication(s) within the past 12 months, or are you currently taking any over-the-counter medication(s) on a weekly basis or more frequently?

Additional Health Questions

1) Have you ever received any advice, treatment, consultation or diagnosis from a physician or health care provider for any of the following conditions? The following conditions require a stability period ranging from 3 months to 5 years to be eligible for coverage. Refer to our Underwriting Guidelines to insure the stability period has been met.
(a) Vision Disorder
(b) Dizziness
(c) Vertigo
(d) Fainting
(e) Head Injury
(g) Neurological Disease/Disorder
(h) Fibromyalgia
(i) Weakness
(j) Fatigue
(k) Stroke
(l) Transient Ischemic Attack
(m) Aneurysm
(n) Carotid Disease/Disorder
(o) Circulatory Disease/Disorder
(p) Seizure
(q) Epilepsy
(r) Tremors
(s) Depression
(t) Anxiety
(u) Mental Disorder
(v) Lung Disease/Disorder
(y) Coronary Artery Disease/Disorder
(z) Heart Disease/Disorder
(aa) High Blood Pressure
(ab) Anemia
(ac) Blood Clotting Disease/Disorder
(ad) Blood Disease/Disorder
(ae) Arthritis
(af) Broken Bone
(ag) Back Disorder
(ah) Spinal Stenosis
(ai) Scoliosis
(aj) Bone or Joint Disorder
(al) Amputation
(an) Osteoporosis
(ao) Osteopenia
(ap) Balance Disorder
(aq) Dificulty Walking
(as) Cancer
(at) Leukemia
(au) Lymphoma
(av) Diabetes
(aw) Immune System Disease/Disorder
(ax) Kidney Disease/Disorder
(ay) Hepatitis
(az) Liver Disease/Disorder
(ba) Shingles
(bb) Incontinence
(bc) Bowel or Bladder Disease/Disorder
2) In the past 5 years, other than (besides) the primary care physician listed in Section E, have you consulted with any (other) medical professional?
3) Do you have, for your use, a handicap parking sticker or handicap license plate?
4) In the past 3 years has a medical professional referred you to a specialist for additional consultation or testing?
5) In the past 3 years has a medical professional referred you to a specialist for surgery?
6) Are you scheduled for a visit with a medical professional within the next 6 months?
7) Have you been seen by your physician, health care provider or any specialist more than three times in the past 12 months?
8) Have you received inpatient or outpatient treatment at a hospital in the past 12 months?
9) Have you received inpatient or outpatient treatment at a surgical center in the past 12 months?
10) Have you received inpatient or outpatient treatment at a rehabilitation facility in the past 12 months?
11) What is your height?
12) What is your weight?
13) Have you had an unplanned weight change in the past 12 months?

Medical Health History

1) To the best of your knowledge has your biological mother, father, or sibling been diagnosed with Alzheimer’s Disease or other form of dementia?
2) Have you been hospitalized or had surgery in the past 3 years?
3) Have you been advised by a member of the medical profession in the last 5 years to have surgery which has not yet been completed?
4) Have you received physical therapy in the past 6 months?
5) Have you received occupational therapy in the past 6 months?
6) Have you received speech therapy in the past 6 months?
7) Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for sleep apnea?
8) Have you used insulin in the past 6 months?
9) Have you ever used tobacco?
10) During the last 10 years, have you ever used unlawful drugs, or used prescription medications other than as prescribed by your doctor?
11) Have you ever received medical treatment, counseling or been hospitalized for drug use?
12) Do you regularly consume 4 or more alcoholic beverages per day, or do you drink 5 or more drinks per day, 1 or more days per week?
13) Have you ever received medical treatment, counseling or been hospitalized for alcohol use?

Premium Information

Applicant A

Applicant B

Payment Authorization

Applicant A

Applicant B

Protection Against Unintentional Lapse

I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long-term care insurance policy for nonpayment of premium. I understand that notice will not be given until thirty (30) days after a premium is due and unpaid.

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