Insurance Long Term Care Application

INSURANCE LONG TERM CARE APPLICATION

Applicant Information

Applicant Name:

Date of Birth:    Gender:

Primary Phone:    Email:

Policy Selection & Premium

Policy Type:

Daily Benefit Amount: $    Benefit Period:

Elimination Period (days):    Inflation Protection: Select if desired

Annual    Monthly EFT    Quarterly    Credit Card

Coverage Options

Select desired coverage elements (select all that apply):

Nursing Facility Care    Home Health Care    Assisted Living Facility    Adult Day Care

Hospice Support Services    Respite Care    Caregiver Training

Health & Medical History

1. Has the applicant ever been diagnosed with or treated for Alzheimer’s disease, dementia, stroke, Parkinson’s disease, multiple sclerosis, or other cognitive disorder?

Yes    No

2. Has the applicant been advised by a healthcare professional in the past 2 years to restrict activities, undergo surgery, or receive ongoing treatment for a chronic condition?

Yes    No

3. In the past 5 years, has the applicant been institutionalized, received skilled nursing care, or received occupational/physical therapy on an ongoing basis?

Yes    No

Additional Information

Does the applicant currently require assistance with any Activities of Daily Living (ADLs) such as bathing, dressing, toileting, transferring, continence, or eating?

Yes    No

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Percentage:

Contingent Beneficiary Name:

Relationship:    Percentage:

Declarations, Authorization & Notice

Certification: I certify that the statements and answers in this application are complete and true to the best of my knowledge and belief. I understand that intentional misstatements or omissions of material facts may result in denial of benefits or rescission of coverage.

Authorization to Obtain Records: I authorize any physician, health care provider, hospital, clinic, medical facility, pharmacy benefit manager, insurance company, or consumer reporting agency to release to the insurer or its authorized representatives any information regarding my medical history, treatment, diagnosis, prognosis, or benefits, and to provide copies of records. This authorization shall remain valid for the purposes of underwriting and claims administration.

Investigative Consumer Report: I understand that an investigative consumer report, including medical and vocational information, may be obtained in connection with this application. I authorize the insurer to obtain such reports and to disclose information to reinsurers as necessary for underwriting.

Fraud Warning: Any person who knowingly presents false information or conceals material information in order to obtain insurance or benefits may be subject to civil or criminal penalties under applicable law.

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