DeclinesIntoCash.com

We help you turn your LTCi declines into approvals!

 

Submit a case for Pre-approval today!

None of the fields on this secure form are required.  However, the more information you provide, the more helpful we can be.  Answer the health questions to the best of your ability.  If you are not sure how to answer a question, then enter "not sure".   

If you'd prefer, you can print out the "pre-approval form" and fax it back to us.

To print out the pre-approval form, click here.

 

    

Your Preferred Phone:

 

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?

What is your client's secondary state of residence,
if any?
 

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:

What is your client's height:
What is your client's current weight:
 

What is your client's history of tobacco use (choose one):


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.