Submit a Long Term Care Comparison

The answers given to the following questions will assist a Long-Term Care Insurance agent to provide a complete and accurate proposal(s) with estimated premium cost. They assist the agent with the three major elements in drafing a policy recomendation. They are:

Suitability

Insurability

Benefit-Structure

Please fill out the following information and press the SUBMIT button. Is the form too long to complete? Call our office directly for a quick, no-obligation quote.

Contact Information:

Name: Date of Birth: Name of Spouse: Date of Birth: Address:   City:   State: Zip: Best time to call: Today's date: Employer:   Occupation: Retired?: Yes No Spouse's Employer:   Occupation: Retired?: Yes No This questionnaire is offered only as a GUIDE to help clairify one's POSSIBLE need for long-term care insurance. 1. While everyone is at risk for he services provided by long-term care professional, not all people ahve the ability to pay for these services or pay for the premium of a long-term are insurance policy. The following questions will help determine your financial risks and premium paying ability. If you are single, do you have over $75,000 of assets? Select One Yes No If you are single, is your annual income for ALL sources over $24,000? Select One Yes No If you are married, do you have over $75,000 of assets excluding your home? Select One Yes No If you are married, is your annual income from ALL sources over $40,000? Select One Yes No If you have children, would they be able to share in the costs of your LTC insurance policy? Select One Yes No 2. Some people might consider self-insuring. If you have a large amont of assets, you may prefer to pay for the cost of nursing care out of your savings. For example, the cost of nurisng homes in the Northeast can range from $55,000 to $100,000 per year. If you (r yor spouse) needed nursing home care, would spending this much per year for Long-Term Care cause a significant change in your lifestyle? Select One Yes No If married, is it of significant importance that your spouse retain most of your assets? Select One Yes No Is it of significant importance that you leave an inheritance for your children or heirs? Select One Yes No 3. Informal care, provided by your family or friends, can postpone and possibly eliminate the need of paid care. Do you have family or friends living with you or close to you who would provide assistance? Select One Yes No Would you feel comfortable having to ask them for assistance? (Examples: Managing medications, dressing, meal preparation, feeding, toileting, etc.) Select One Yes No Could they afford to take time away from work in order to provide you assistance? Select One Yes No Could they afford to take time away from their family in order to provide you assistance? Select One Yes No Could you move in with them? Select One Yes No Would you ant to move in with them? Select One Yes No Could they bathe you? Select One Yes No Could they lift you up from a chair or bed? Select One Yes No Could they carry you out of the house? Select One Yes No 4. How you feel about "Choice" will also determine if long-term care insurance is right for you. Welfare (Medicaid) was designed as the last resort for widows and children with no other place to turn. Yet, some people hide their assets in Irrevocable Trust to qualify for welfare. (1993 Medicaid rules for trusts created a 60-month look-back period, for transfers.) Do you feel people with means have an obligation to pay for their own nursing care costs? Select One Yes No In order to qualify for welfare, one must spend down all their assets to the poverty level and relinquish most of their income. Would this matter to you? Select One Yes No On welfare (Medicaid), nursing home care can be rendered up to a 50-mile radius from your home. Would this matter to you? Select One Yes No 5. Health history is an important factor in qualifying for LTC insurance. Although insurance companies do not expect you to have the health of a 20-year-old, they do want you to be in "fairly" good health for your age. Are you dependent on the use of a walker or wheelchair or confiend to bed or home? Select One Yes No Is your spouse dependent on the use of a walker or wheelchair or confined to a bed or home? Select One Yes No Do you use any medical appliance such as a catheter, oxygen, respirator, or dialysis machine? Select One Yes No Does your spouse use any medical appliance such as a catheter, oxygen, respirator, or dialysis machine? Select One Yes No In the past TEN years, have you, (or your spouse), been hospitalized for any reason? Select One Yes No If "YES", list the name of the person who had the hospital stay, the reason for thestay and the date of the hospital stay(s).   Name:   Reason for stay:   Date of stay: In the past TEN years, have you, (or your spouse), taken a prescribed medication? Select One Yes No If "YES", list the name of the person taking the medication, the complete name of the medication, the amount taken per day, and the purpose for taking the medication.   Name:   Medication:   Amount:   Purpose: In the past FIVE years, have you, (or your spouse), seen a medical doctor? Select One Yes No If "YES", list the name of the person who saw the doctor and the reason for seeing th doctor.   Name:   Reason : In the past FIVE years, have you, (or your spouse), used any tobacco products, including cigarettes, pipe,cigar, or chewing tobacco? Select One Yes No If "YES", please list who used or uses tobacco products.   Name: What is your height and weight? (height) (weight) Your spouse's height and weight? (height) (weight) The dollar value of the assets you wish to protect: $ Household income: $

NOTE: Premium quotes are based on the rates effective at the time the quotation is made. They are for informational purposes only and are subject to the accuracy of the information provided by the individual requesting the quote.

This is not an implicit offer of insurance. Actual rate quotations are based on an individual customer needs analysis and are calculated with specific information provided by the applicant to the agent. Products and services may not be available in all states and are subject to all eligibility requirements stated in the policy.

Copyright © 2010 Osby Insurance and Some Assembly Required.
All rights reserved.