Your contact information:

Your First Name:      
Your Last Name: 
Your preferred e-mail address:
Your Preferred Phone:

 

Your client's health history:

Which Insurer(s) has previously declined your client:

To the best of your knowledge, what was the reason(s)
our client was declined:
 

Many long term care insurers have slightly different underwriting standards and even different premiums, depending upon the state in which the applicant resides.  To make sure we get the best possible coverage for your client, please answer the following questions regarding your client's state of residence:

What is your client's primary state of residence? --None--ALABAMA AL ALASKA AK ARIZONA AZ ARKANSAS AR CALIFORNIA CA COLORADO CO CONNECTICUT CT DELAWARE DE DISTRICT OF COLUMBIA DC FLORIDA FL GEORGIA GA HAWAII HI IDAHO ID ILLINOIS IL INDIANA IN IOWA IA KANSAS KS KENTUCKY KY LOUISIANA LA MAINE ME MARYLAND MD MASSACHUSETTS MA MICHIGAN MI MINNESOTA MN MISSISSIPPI MS MISSOURI MO MONTANA MT NEBRASKA NE NEVADA NV NEW HAMPSHIRE NH NEW JERSEY NJ NEW MEXICO NM NEW YORK NY NORTH CAROLINA NC NORTH DAKOTA ND OHIO OH OKLAHOMA OK OREGON OR PENNSYLVANIA PA RHODE ISLAND RI SOUTH CAROLINA SC SOUTH DAKOTA SD TENNESSEE TN TEXAS TX UTAH UT VERMONT VT VIRGINIA VA WASHINGTON WA WEST VIRGINIA WV WISCONSIN WI WYOMING WY

What is your client's secondary state of residence,
if any? --None--ALABAMA AL ALASKA AK ARIZONA AZ ARKANSAS AR CALIFORNIA CA COLORADO CO CONNECTICUT CT DELAWARE DE DISTRICT OF COLUMBIA DC FLORIDA FL GEORGIA GA HAWAII HI IDAHO ID ILLINOIS IL INDIANA IN IOWA IA KANSAS KS KENTUCKY KY LOUISIANA LA MAINE ME MARYLAND MD MASSACHUSETTS MA MICHIGAN MI MINNESOTA MN MISSISSIPPI MS MISSOURI MO MONTANA MT NEBRASKA NE NEVADA NV NEW HAMPSHIRE NH NEW JERSEY NJ NEW MEXICO NM NEW YORK NY NORTH CAROLINA NC NORTH DAKOTA ND OHIO OH OKLAHOMA OK OREGON OR PENNSYLVANIA PA RHODE ISLAND RI SOUTH CAROLINA SC SOUTH DAKOTA SD TENNESSEE TN TEXAS TX UTAH UT VERMONT VT VIRGINIA VA WASHINGTON WA WEST VIRGINIA WV WISCONSIN WI WYOMING WY
 

Because many health conditions are underwritten differently depending upon one's age, what is your client's date of birth:

What is your client's gender: --None--Gender Male Female

What is your client's height: --None--4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11" 7'0"
What is your client's current weight:
 

What is your client's history of tobacco use (choose one): --None--Never used No tobacco use in over 5 years No tobacco use in over 3 years No tobacco use in over 12 months Celebratory Cigar Use Currently smokes cigarettes Currently uses other types of tobbaco (not cigarettes)

Please list your client's prescription medications as well as the reasons for which the prescriptions are taken.  If you know the dosages, that would be very helpful:

 

Check the following box if your client has received any type of disability benefits or worker's compensation in the past 5 years:

Please provide as much detail as possible in the boxes below if your client has been treated for any of the following conditions
in the past 10 years:

Stroke, CVA or TIA (mini-stroke):


Any type of of Diabetes:


Any type of Heart Disease:


Any type of cancer:


Any type Hepatitis:


Any injuries from falls or any broken bones or fractures:


Any chronic illness not yet mentioned:


Any surgery or hospital stay (not previously mentioned):


Any other health problems or any other details you'd like to add,
please enter them in the box below:

 

Click this "Submit Query" button

and we'll get right to work
on pre-approving your client.

If we need additional information in order to pre-approve your client, we'll e-mail you within 24 hours with any additional questions.