Memorial Financial Services - Long Term Care Quote

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Long Term Care Quote

Long Term Care Insurance Quote

First Name:

Last Name:

Daytime Telephone:

Evening Telephone:

Email:

Address:

City:

State:

Zip:

About You:

Your Birth Date

Your Gender

Male Female

Your Height
Feet plus inches (example 5'6")

Your Weight

Are You Married?

Yes No
Spouse's Birth Date

Please Complete For Self/Spouse

	Self	Spouse
Do you smoke?	Yes No	Yes No
Are you diabetic?	Yes No	Yes No
Are you insulin dependent?	Yes No	Yes No
Do you use a cane?	Yes No	Yes No
Do you use a walker?	Yes No	Yes No
Do you use a wheel chair?	Yes No	Yes No
Do you use any other equipment?	Yes No	Yes No
If you have required assistance with everyday activities in the past 2 years, please explain
In the past 5 years have you:	Self	Spouse
been confined to a hospital?	Yes No	Yes No
nursing home?	Yes No	Yes No
had home care?	Yes No	Yes No
had long-term care?	Yes No	Yes No
received rehabilitation?	Yes No	Yes No
Please describe your particular health problems
Prescribed medications
Do you currently own a long-term care policy?	Yes No	Yes No

Long-Term Care Quote Selections

Benefit period desired (Average stay in a nursing facility is about 3 years)

Daily Benefit - nursing home coverage

Daily benefit - home & community care

How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc? The average cost per month is $5,000 which could be more depending on area of country

Inflation protection/cost-of living adjustment Most needed for younger applicants

Comments or Questions:

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