Long-Term Care Insurance Health Prescreen Form

Not an application for insurance. This Prescreen Form is used exclusively to gather specific information on a proposed insured’s medical history and other factors that may impact underwriting and rating classifications.

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Gender
Are you married?
Are you a U.S. Citizen?
Have you had any weight loss in the last 12 months?
Do you or have you ever used tobacco products?
Are you a current user?
Do you currently have another long-term care insurance, nursing home and home care, nursing home only, home health care, accident and health policy or certificate in-force (including a health care service, health maintenance organization, Medicare Supplement contract or life insurance with long-term care coverage)?
Have you had another long-term care insurance, nursing home and home care, nursing home only, home health care policy or certificate in-force during the last 12 months?
Do you intend to replace any of your long-term care coverage, nursing home and home care, nursing home only, home health care, medical or health insurance coverage with the policy for which you are applying?
Have you ever been declined, rated or denied reinstatement for long-term care insurance?
Do you currently use any of the following?
Have you been confined to, or been advised to have, or used any of the following:
Have you been medically advised to enter or been confined to a hospital or other health care facility?
Do you require assistance or supervision of another person or a device of any kind for any of the following? Bathing, toileting, dressing, eating, walking, medication management, getting in and out of a chair or bed, or control of your bowel or bladder?
Do you require assistance with shopping, using transportation or housekeeping/cooking?
Do you have diabetes?
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Do you have diabetes in combination with any of the following (please check all that apply):
Have you ever been diagnosed with cancer?
Have you ever been diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Emphysema or Chronic Bronchitis or Asthma?
Do you have congestive heart failure in combination with any of the following (please check all that apply):
Have you ever been diagnosed or treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC), any other sickness or condition derived from such infection, or tested positive for HIV or exposure to the HIV infection?
Have you ever talked to your doctor about memory loss? Is memory loss noted in your medical records?
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