Quote Request: Long Term Care | LLIS

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Quote Request: Long Term Care

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential: please see our Privacy Policy. Please do not hit "Enter" or click "Send Quote Request" until the form has been completed. For serious health problems or unusual circumstances, please call (toll free) 877-254-4429 for a no-cost, confidential consultation. *Red = Required Field.

Advisor Information

Financial Advisor Name *

Financial Advisor Company

Proposed Insured

First Name *

Middle Name

Last Name *

Preferred Name / Nickname

Date of Birth (MM/DD/YYYY) *

Are you a U.S. Citizen? *

Yes No Unknown Unanswered

Immigration Status *

Permanent Resident/Green Card Holder Visa Holder

Country of Birth *

Date of Entry *

Visa/Green Card Type *

Visa/Green Card Expiration Date *

Contact Information

Preferred Contact Number *

Email Address *

Current Address

Address

Address 2 (Apt, Suite, etc...)

City *

Zip Code

Household Information

Marital Status *

Number of Children *

Ages of Children

Occupation

Are you currently employed? *

Yes No Unknown Unanswered

Occupation *

Annual Earned Income ($) *

Please select: *

Stay at home parent Retired Other

Please explain *

Health Details

Weight (lbs) *

Gender *

Male Female

Are you currently pregnant? *

Yes No Unknown Unanswered

What's your approximate due date? *

How much weight have you gained so far? *

Are you currently undergoing IVF? *

Yes No Unknown Unanswered

Please provide details including treatments, procedures and dates *

Even if not currently pregnant, have you had a history of gestational diabetes, complications or a history of multiple births with any pregnancies? *

Have you had any weight loss or gain of more than 10 lbs. in the last year? *

Yes No Unknown Unanswered

Please indicate amount of weight gain or loss, and reason: *

Have you EVER been diagnosed with, treated for, hospitalized for or been advised to seek treatment for:

High blood pressure? *

Yes No Unknown Unanswered

Please provide date of diagnosis, medications (name, dosage, and frequency), last date of treatment (if applicable), & last reading/test result *

Example: Diagnosed with elevated blood pressure 2 years ago – take 20 mg Lisinopril daily – last reading 128/82

High cholesterol or high triglycerides? *

Yes No Unknown Unanswered

Please provide: Specific condition/diagnosis, date of diagnosis, any medications (name, dosage and frequency), last date of treatment (if applicable), and last reading/test result *

Example: High Cholesterol – July 2014 – take Crestor 20mg / day – had physical in May – readings were great

Heart attack or coronary artery disease? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Heart murmur, angina or chest pain, palpitations, irregular heart beat or other heart conditions? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Circulatory system disorder, thrombophlebitis, aneurysm, embolism, peripheral vascular disease or edema? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Migraines or chronic headaches? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, any medications (name, dosage and frequency), & how many work days you miss per year due to this condition: *

Seizures, fainting, dizziness, vertigo, epilepsy, stroke or mini stroke (TIA – transient ischemic attack), paralysis, carotid artery blockage, or other nervous system or brain disorder? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Anemia, leukemia, clotting disorder, or any other blood disorder? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Diabetes, elevated blood sugar, a disorder of the urinary tract or findings of sugar, protein or blood in the urine, or kidney disease? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Asthma? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Emphysema, chronic obstructive pulmonary disease (COPD), shortness of breath, tuberculosis, sarcoidosis, persistent hoarseness, bronchitis or any other disorder of the lungs or respiratory system? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Arthritis, osteoporosis/osteopenia, gout, fibromyalgia, carpal tunnel or any injury/disorder of the back, spine, muscles, nerves, bones, joints or skin (such as psoriasis)? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Alcohol or drug abuse? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Elevated liver functions, ulcers, jaundice, hepatitis, cirrhosis, gastrointestinal bleeding, or other disorder of the stomach, esophagus, liver, intestines, gallbladder or pancreas? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Disorder of the reproductive organs, or sexually transmitted diseases? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Thyroid, pituitary or other endocrine or glandular disorder? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Any immune disorder or allergies? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Do you use or have a prescription for an epi-pen? *

Yes No Unknown Unanswered

Please specify how many times you use it per year, and date of last use: *

Anxiety? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Depression? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

ADD, ADHD or any other nervous, mental, emotional, mood or eating disorders? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Alzheimer's or other cognitive disorder? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Have you ever attempted suicide or had suicidal thoughts/ideations? *

Yes No Unknown Unanswered

Please describe: *

Any disorder of the eyes, ears, nose or throat? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Ever been diagnosed or treated for AIDS or AIDS related conditions or tested positive for the presence of HIV antibodies, antigens or the virus? *

Yes No Unknown Unanswered

Please provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) *

Are you planning to seek medical advice or treatment for any reason; are you scheduled for a medical test or appointment or have you been advised to schedule a follow up medical appointment or test? *

Yes No Unknown Unanswered

Please provide doctor's contact information, date/reason for visit, and any diagnostic tests being performed (if applicable): *

Have you had a positive COVID-19 test, genetic testing or any hospitalizations or surgeries in the last 10 years (or longer if significant or voluntary such as such as organ donation, preventative mastectomy or gender reassignment? *

Yes No Unknown Unanswered

Please provide details about dates, treatments, medications and dosages, and follow-ups. *

Are you currently taking any other medications or supplements other than those listed above? *

Yes No Unknown Unanswered

Please describe: *

In the last 5 years, were you prescribed any medications that you are NOT currently taking, other than cold, flu or birth control? *

Yes No Unknown Unanswered

Please provide the diagnosis, medication name, dosage and dates taken and if the condition is resolved: *

LTC Coverage

Inflation Coverage: *

None Compound 3% Compound 4% Compound 5%

Home Daily Benefit Amount ($): *

Home Care Benefit is 100% of Nursing Home Benefit

Premium Mode: *

Annual Monthly Bank Draft

Other Riders:

Are you currently receiving disability payments? *

Yes No Unknown Unanswered

Please provide date payments began and reason: *

Are you currently using any assistance devices? *

Yes No Unknown Unanswered

Please describe devices and how long you've been using them: *

Have you had any physical therapy in the last 6 months? *

Yes No Unknown Unanswered

Please describe: *

Do you have any existing LTC coverage? *

Yes No Unknown Unanswered

Please List Individual Policies *

Individual Policy 1

Benefit Amount ($) *

Benefit Period *

Elimination Period *

Add Individual Policy

Have you ever been declined LTC coverage? *

Yes No Unknown Unanswered

Please explain why: *

Is there any history of cognitive impairment or Alzheimer's Disease in your immediate family? *

Yes No Unknown Unanswered

Please explain: *

In the last five years, have you used tobacco in any form including cigars, cigarettes, pipe, chew, or nicotine products such as nicotine patch, nicotine gum, or e-cigarettes / vapor? *

Yes No Unknown Unanswered

Please list each tobacco/nicotine type: *

Tobacco/Nicotine Type 1

Amount/Frequency *

Example: 1 pack daily

Date Last Used *

Add Tobacco/Nicotine Type

Have you used marijuana in the last 3 years? *

Yes No Unknown Unanswered

Please describe details including

Frequency (# per week, month or year)
Date last used
How it is used (smoked, ingested, edibles, vape, etc.)
Recreational or medical use
- If medical use, do you have a prescription and what is the diagnosis?

Any/all information helps us find the best rates *

Do you consume alcohol? *

Yes No Unknown Unanswered

Type of Alcohol *

How Much? *

How often? *

Do you have a spouse/partner? *

Yes No Unknown Unanswered

Is he/she also applying for coverage? *

Yes No Unknown Unanswered

Spouse/Partner First Name *

Spouse/Partner Last Name *

Spouse/Partner Date of Birth *

** Please have your spouse/partner complete his/her own quote request.

Delivery Options

Date Quote Needed By *

Send Quote To *

Myself & Copy Advisor Advisor Only

Additional Details

Additional details you'd like to include to help us with the quote.