Long-Term Care Evaluation
Husband's Name:		SS#:		Birthdate:
Wife's Name :		SS#:		Birthdate:

Address:
	Street:
	City:	State: ZIP:
Phone:
	Home:	Work:

			Husband	Wife
1.	Height
2.	Weight
3.	Do you need or receive assistance or supervision for walking, transferring, eating, toileting, breathing, or dressing?		Yes No	Yes No
4.	Are you currently in a hospital or LTC facility, or receiving home health care?		Yes No	Yes No
5.	Have you been diagnosed with or treated for the following:
	a.	Alzheimer's Disease	Yes No	Yes No
	b.	Dementia	Yes No	Yes No
	c.	Senility	Yes No	Yes No
	d.	Organic Brain Syndrome (any type)	Yes No	Yes No
	e.	Parkinson's Disease	Yes No	Yes No
	f.	AIDS	Yes No	Yes No
	g.	AIDS-Related Complex	Yes No	Yes No
	h.	Human Immunodeficiency Virus	Yes No	Yes No
6.	In the last five years, have you:
	a.	Been, or been advised to be, hospitalized?	Yes No	Yes No
	b.	Been, or been advised to be, confined to a nursing home?	Yes No	Yes No
	c.	Received, or been advised to receive, home health care?	Yes No	Yes No
7.	Have you used a cane, walker, or wheelchair in the last two years?		Yes No	Yes No
8.	Have you ever had an application for life or health insurance declined, rated, modified, or postponed?		Yes No	Yes No
9.	Have you ever received disability benefits at any time?		Yes No	Yes No
10.	Within the past 12 months, have you required or received assistance with shopping, cleaning, cooking, laundry, or transportation?		Yes No	Yes No
11.	Within the last five years, have you received any medical or surgical advice, examination, or treatment for:
	a.	Cancer, leukemia, or Hodgkin's Disease?	Yes No	Yes No
	b.	Stroke, TIA, epilepsy, or seizures?	Yes No	Yes No
	c.	Depression, psychosis, or any other mental, nervous, emotional or brain disorder?	Yes No	Yes No
	d.	Nephristis, kidney failure, incontinence, cirrhosis of the liver, or diabetes	Yes No	Yes No
	e.	Osteoporosis, arthritis, or any back, spine, bone, joint, or muscle disease or disorder?	Yes No	Yes No
	f.	Heart disorder, hypertension, cystic fibrosis, emphysema, or other lung disease or disorder?	Yes No	Yes No
	g.	Drug or alcohol abuse?	Yes No	Yes No
12.	Within the last five years, have you received any medical or surgical advice, examination or treatment for any condition not included in the above medical/health questions?		Yes No	Yes No
13.	List all medications currently being taken:
	Husband     Medication Name Condition Name Dosage 1. 2. 3. 4. 5. 6. Wife     Medication Name Condition Name Dosage 1. 2. 3. 4. 5. 6.
14.	Within the past 12 months, have you had another LTC Nursing Home and/or Home Care policy?		Yes No	Yes No
15.	Do you intend to replace any insurance with this policy?		Yes No	Yes No
16.	Do you have a Medicare Supplement Policy?		Yes No	Yes No
		If so, with what company do you have your coverage?

17.	What is your annual income?	Under $10,000 $10,000–$19,999 $20,000–$29,999 $30,000–$39,999 $40,000–$49,999 $50,000 or Over
18.	Where will the premium for this policy be paid from?	Personal income Savings Family Other
19.	Do you expect your income to change over the next 10 years?	No change Increase Decrease

20.	Other information: