ARG & Associates will provide you with a free, no-obligation Individual Long-Term Care quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.

Individual Long-Term Care

Personal Information

Name:                        Date:

Address:

City:

State:

Zip:

Phone:                      Best time to call:   am    pm

E-mail:

Insurance Information

Currently Insured with:

Policy Number:            Policy Expiration Date:

Premium Amount: $       Insured Amount: $

Term of Insurance:  6 months    1 year    other:

Current or previous Insurance Information

Do you currently have Long-Term care insurance policy, rider or certificate (including heath care or health maintenance:  Y    N

Did you previously have Long-Term Care insurance policy, rider or certificate in the past 12 months?:  Y    N If yes, please list (mm/dd/yy):

Are you covered by state assistance program:  Y    N

Do you intend to replace any of your medical or health insurance coverage with this policy, rider certificate:  Y    N

Does your company currently offer long-term care or disability benefits?  Y    N

Have you ever been denied coverage for medical insurance, disability insurance, long-term care insurance or life insurance?  Y    N

If you answered yes to any of the questions above please explain below:

Medical Information

1st Insured/Primary
Name:        Date of Birth:      Sex:  Male    Female
Marital Status:  Married    Single
Occupation:
Weight:      Height:      feet  Inches
Health History
Have you been hospitalized in the past 12 months?  Y    N
Has a medical professional admitted you to a hospital or nursing home in the past 24 months?  Y    N
Have you had any surgery in the past 24 months?  Y    N
Do you need supervision or assistance from another individual with everyday activities or to tending to your personal needs?  Y    N
Do you need help or assistance from another person to handle your finances, shopping, laundry or using the telephone?  Y    N
Do you need a walker, wheelchair, cane, crutches, or any other devices?  Y    N
Do you use any prescribed medical devices or appliances?  Y    N
If you answered Yes to any of the questions above please explain in the space provided below:
Health History (continued)
If you have had any of the following in the past 5 years please explain in the large section provided below:
Do you have or have you had in the past 5 years:
Osteoarthritis?  Yes    No	Shortness of breath?  Yes    No
Osteoporosis?  Yes    No	Heart disease or circulatory system?  Yes    No
Amputation?  Yes    No	High Blood Pressure?  Yes    No
Bone or joint disease?  Yes    No	Heart attack?  Yes    No
Rheumatoid arthritis?  Yes    No	Angina?  Yes    No
Spinal stenosis?  Yes    No	Psychiatric or mental disorders?  Yes    No
Internal cancer  Yes    No	Psychological disorders?  Yes    No
Tumor?  Yes    No	Depression?  Yes    No
Leukemia?  Yes    No	Anxiety?  Yes    No
Lymphoma?  Yes    No	Neurological disorders?  Yes    No
Hodgkin's disease?  Yes    No	Parkinson's disease?  Yes    No
Kidney disease?  Yes    No	Multiple sclerosis?  Yes    No
Stomach disease?  Yes    No	Alzheimer's disease?  Yes    No
Liver disease?  Yes    No	Stroke/TIA?  Yes    No
Pancreas disease?  Yes    No	Paralysis?  Yes    No
Disease of the small or large intestine?  Yes    No	Convulsions?  Yes    No
Cirrhosis?  Yes    No	Epilepsy?  Yes    No
Diabetes or thyroid disease?  Yes    No	Seizures or Muscular dystrophy?  Yes    No
Lung disease?  Yes    No	Acquired Immune Deficiency Syndrome (AIDS)?  Yes    No
Respiratory system?  Yes    No	HIV Positive?  Yes    No
Emphysema?  Yes    No	Treatment or counseling for alcohol abuse?  Yes    No
Asthma?  Yes    No	Treatment or counseling for drug abuse?  Yes    No
Explanations:
Medications
Do you currently take any medications?  Yes    No, if yes, please list below;
Tobacco Products
Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:
Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?
Are you currently using Tobacco products?  Yes       No, if yes, please answer below:
What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:
How long have you been using tobacco products?
Current Insurance Information
Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:
Carriers Name:
Policy Number:            Policy Expiration Date:
Premium Amount: $
Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

2nd Insured/Spouse Partner
Name:        Date of Birth:      Sex:  Male    Female
Marital Status:  Married    Single
Occupation:
Weight:      Height:      feet  Inches
Health History
Have you been hospitalized in the past 12 months?  Y    N
Has a medical professional admitted you to a hospital or nursing home in the past 24 months?  Y    N
Have you had any surgery in the past 24 months?  Y    N
Do you need supervision or assistance from another individual with everyday activities or to tending to your personal needs?  Y    N
Do you need help or assistance from another person to handle your finances, shopping, laundry or using the telephone?  Y    N
Do you need a walker, wheelchair, cane, crutches, or any other devices?  Y    N
Do you use any prescribed medical devices or appliances?  Y    N
If you answered Yes to any of the questions above please explain in the space provided below:
Health History (continued)
If you have had any of the following in the past 5 years please explain in the large section provided below:
Do you have or have you had in the past 5 years:
Osteoarthritis?  Yes    No	Shortness of breath?  Yes    No
Osteoporosis?  Yes    No	Heart disease or circulatory system?  Yes    No
Amputation?  Yes    No	High Blood Pressure?  Yes    No
Bone or joint disease?  Yes    No	Heart attack?  Yes    No
Rheumatoid arthritis?  Yes    No	Angina?  Yes    No
Spinal stenosis?  Yes    No	Angina?  Yes    No
Internal cancer  Yes    No	Psychological disorders?  Yes    No
Tumor?  Yes    No	Depression?  Yes    No
Leukemia?  Yes    No	Anxiety?  Yes    No
Lymphoma?  Yes    No	Neurological disorders?  Yes    No
Hodgkin's disease?  Yes    No	Parkinson's disease?  Yes    No
Kidney disease?  Yes    No	Multiple sclerosis?  Yes    No
Stomach disease?  Yes    No	Alzheimer's disease?  Yes    No
Liver disease?  Yes    No	Stroke/TIA?  Yes    No
Pancreas disease?  Yes    No	Paralysis?  Yes    No
Disease of the small or large intestine?  Yes    No	Convulsions?  Yes    No
Cirrhosis?  Yes    No	Epilepsy?  Yes    No
Diabetes or thyroid disease?  Yes    No	Seizures or Muscular dystrophy?  Yes    No
Lung disease?  Yes    No	Acquired Immune Deficiency Syndrome (AIDS)?  Yes    No
Respiratory system?  Yes    No	HIV Positive?  Yes    No
Emphysema?  Yes    No	Treatment or counseling for alcohol abuse?  Yes    No
Asthma?  Yes    No	Treatment or counseling for drug abuse?  Yes    No
Explanations:
Medications
Do you currently take any medications?  Yes    No, if yes, please list below;
Tobacco Products
Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:
Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?
Are you currently using Tobacco products?  Yes       No, if yes, please answer below:
What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:
How long have you been using tobacco products?
Current Insurance Information
Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:
Carriers Name:
Policy Number:            Policy Expiration Date:
Premium Amount: $
Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

3rd Insured
Name:        Date of Birth:      Sex:  Male    Female
Marital Status:  Married    Single
Occupation:
Weight:      Height:      feet  Inches
Health History
Have you been hospitalized in the past 12 months?  Y    N
Has a medical professional admitted you to a hospital or nursing home in the past 24 months?  Y    N
Have you had any surgery in the past 24 months?  Y    N
Do you need supervision or assistance from another individual with everyday activities or to tending to your personal needs?  Y    N
Do you need help or assistance from another person to handle your finances, shopping, laundry or using the telephone?  Y    N
Do you need a walker, wheelchair, cane, crutches, or any other devices?  Y    N
Do you use any prescribed medical devices or appliances?  Y    N
If you answered Yes to any of the questions above please explain in the space provided below:
Health History (continued)
If you have had any of the following in the past 5 years please explain in the large section provided below:
Do you have or have you had in the past 5 years:
Osteoarthritis?  Yes    No	Shortness of breath?  Yes    No
Osteoporosis?  Yes    No	Heart disease or circulatory system?  Yes    No
Amputation?  Yes    No	High Blood Pressure?  Yes    No
Bone or joint disease?  Yes    No	Heart attack?  Yes    No
Rheumatoid arthritis?  Yes    No	Angina?  Yes    No
Spinal stenosis?  Yes    No	Angina?  Yes    No
Internal cancer  Yes    No	Psychological disorders?  Yes    No
Tumor?  Yes    No	Depression?  Yes    No
Leukemia?  Yes    No	Anxiety?  Yes    No
Lymphoma?  Yes    No	Neurological disorders?  Yes    No
Hodgkin's disease?  Yes    No	Parkinson's disease?  Yes    No
Kidney disease?  Yes    No	Multiple sclerosis?  Yes    No
Stomach disease?  Yes    No	Alzheimer's disease?  Yes    No
Liver disease?  Yes    No	Stroke/TIA?  Yes    No
Pancreas disease?  Yes    No	Paralysis?  Yes    No
Disease of the small or large intestine?  Yes    No	Convulsions?  Yes    No
Cirrhosis?  Yes    No	Epilepsy?  Yes    No
Diabetes or thyroid disease?  Yes    No	Seizures or Muscular dystrophy?  Yes    No
Lung disease?  Yes    No	Acquired Immune Deficiency Syndrome (AIDS)?  Yes    No
Respiratory system?  Yes    No	HIV Positive?  Yes    No
Emphysema?  Yes    No	Treatment or counseling for alcohol abuse?  Yes    No
Asthma?  Yes    No	Treatment or counseling for drug abuse?  Yes    No
Explanations:
Medications
Do you currently take any medications?  Yes    No, if yes, please list below;
Tobacco Products
Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:
Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?
Are you currently using Tobacco products?  Yes       No, if yes, please answer below:
What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:
How long have you been using tobacco products?
Current Insurance Information
Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:
Carriers Name:
Policy Number:            Policy Expiration Date:
Premium Amount: $
Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

4th Insured
Name:        Date of Birth:      Sex:  Male    Female
Marital Status:  Married    Single
Occupation:
Weight:      Height:      feet  Inches
Health History
Have you been hospitalized in the past 12 months?  Y    N
Has a medical professional admitted you to a hospital or nursing home in the past 24 months?  Y    N
Have you had any surgery in the past 24 months?  Y    N
Do you need supervision or assistance from another individual with everyday activities or to tending to your personal needs?  Y    N
Do you need help or assistance from another person to handle your finances, shopping, laundry or using the telephone?  Y    N
Do you need a walker, wheelchair, cane, crutches, or any other devices?  Y    N
Do you use any prescribed medical devices or appliances?  Y    N
If you answered Yes to any of the questions above please explain in the space provided below:
Health History (continued)
If you have had any of the following in the past 5 years please explain in the large section provided below:
Do you have or have you had in the past 5 years:
Osteoarthritis?  Yes    No	Shortness of breath?  Yes    No
Osteoporosis?  Yes    No	Heart disease or circulatory system?  Yes    No
Amputation?  Yes    No	High Blood Pressure?  Yes    No
Bone or joint disease?  Yes    No	Heart attack?  Yes    No
Rheumatoid arthritis?  Yes    No	Angina?  Yes    No
Spinal stenosis?  Yes    No	Angina?  Yes    No
Internal cancer  Yes    No	Psychological disorders?  Yes    No
Tumor?  Yes    No	Depression?  Yes    No
Leukemia?  Yes    No	Anxiety?  Yes    No
Lymphoma?  Yes    No	Neurological disorders?  Yes    No
Hodgkin's disease?  Yes    No	Parkinson's disease?  Yes    No
Kidney disease?  Yes    No	Multiple sclerosis?  Yes    No
Stomach disease?  Yes    No	Alzheimer's disease?  Yes    No
Liver disease?  Yes    No	Stroke/TIA?  Yes    No
Pancreas disease?  Yes    No	Paralysis?  Yes    No
Disease of the small or large intestine?  Yes    No	Convulsions?  Yes    No
Cirrhosis?  Yes    No	Epilepsy?  Yes    No
Diabetes or thyroid disease?  Yes    No	Seizures or Muscular dystrophy?  Yes    No
Lung disease?  Yes    No	Acquired Immune Deficiency Syndrome (AIDS)?  Yes    No
Respiratory system?  Yes    No	HIV Positive?  Yes    No
Emphysema?  Yes    No	Treatment or counseling for alcohol abuse?  Yes    No
Asthma?  Yes    No	Treatment or counseling for drug abuse?  Yes    No
Explanations:
Medications
Do you currently take any medications?  Yes    No, if yes, please list below;
Tobacco Products
Have you ever used any tobacco products?  Yes       No, if yes, please answer the questions below:
Have you quit using tobacco products?  Yes       No, if yes, how long ago did you quit?
Are you currently using Tobacco products?  Yes       No, if yes, please answer below:
What type of tobacco products are you using?  Cigarette    Cigar    Pipe    Smokeless  Other:
How long have you been using tobacco products?
Current Insurance Information
Do you currently have health insurance coverage?  Yes       No, if yes, please answer the information below:
Carriers Name:
Policy Number:            Policy Expiration Date:
Premium Amount: $
Please indicate whether the premium is:  Monthly    Quarterly    Bi-Annual    Annual  Other:

Additional Details

Please list below any additional details about your health or anyone else to be insured in the space provided below:

When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.

      

  This Form: ILTC2020 is a Copyright © 2003 First e-Commerce Corporation