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LONG TERM CARE INSURANCE:   click for more information At AllInsuranceNeedz.com, we put the power of the internet to work for you! In just a moment we'll search our nationwide database for a qualified insurance provider who can offer you the most appropriate coverage and the most competitive quote! First, we need some information about you. Please take a moment to answer the following questions. Remember, this information is needed to find the best agent with the best rate for you, so please answer it as accurately and completely as possible We'll begin by asking for a little information about you. Your answers to the following questions will enable us to determine whether long term care is a wise choice for your present and future insurance needs. 1) What is your gender? M F 2) What is your date of birth? MM/DD/YYYY 3) If you are age 65 or over, are you eligible for Medicaid? Yes No 4) What is your height? ft. in. 5) What is your weight? lbs. 6) Please indicate your marital status: Select Single Single-Parent Married Separated Divorced Widowed 7) What is the highest level of education you completed? Select None or Incomplete Education High School Diploma GED Some College College Degree Masters Degree PhD 8) Please indicate your current employment status: Select Full Time Part Time In Transition Retired Homemaker Student Other 9) Please select the industry that best describes your occupation: Select One Computers --Graphics --Operator/Technician --Programmer Engineering --Aerospace --Chemical --Civil --Electrical --Mechanical --Nuclear --Other Construction --Contractor --Electrician --Installer --Mechanic --Painter --Plumber --Welder Education --Administration --College Professor --Professional Instructor --Teacher Healthcare --Administration --Dentist/Dental Technician --Lab Technician --Nurse/Paramedic --Pharmacist --Physician/Surgeon --Psychiatrist/Psychologist/Social Worker --Hospitality/Recreation/Travel --Airline Employee --Amusement Parks/Recreation Centers --Driving --Hotel Services --Restaurant Services --Travel Agent Manufacturing --Assembly --Machine Operator --Maintenance --Printing Professional --Accounting --Architecture --Art/ Photography --Entertainment/Performing --Financial Services --Insurance --Interior Design --Journalism --Law/Legal Services --Marketing & Sales --Membership Organizations --Real Estate --Sports/Fitness/Nutrition Private Sector --Child Care --Cleaning Services --Homemaker --Landscaping/Gardening --Personal Assistant Public Service --Civil Service --Economic Administration --Environmental Administration --Executive Legislative --Fire Fighter --Government Employee --Human Resources --International Affairs --Justice, Public Order and Safety --Military Officer --National Security --Police Department --Postal Service --Public Transportation --Social Worker Retail --Auto Dealer/Service Center --Consumer Services/Sales --Management --Merchandising --Product Sales --Security Other-Not Listed Retired Self Employed Student Unemployed Veteran 10) How long have you been employed at your present job? Years Months To help us ensure that our search delivers the most competitive quote for your insurance needs, we'll need some information about your day-to-day lifestyle, your medical history and your current health status. Please continue by answering the following set of questions to the best of your knowledge 11) In the past five years, have you used any form of tobacco or nicotine substitute? Select One Never 1-12 month(s) 13-24 months 25-36 months 37-48 months 49-60 months 12) If Yes, what forms of tobacco did you use? Smoke Cigarettes Smoke Cigars Smoke A Pipe Chew Tobacco Chew Nicotine Gum 'The Patch' 13) If you currently smoke cigarettes, how many packs do you smoke per day? Select One Under 1 1 To 2 Over 2 14) Have you used any form of alcohol in the past five years? Yes No 15) If so, what do you usually drink? Beer Wine Liquor 16) Have you been treated by a physician in the last year? Yes No 17) Have you been hospitalized in the last five years? Yes No 18) Are you currently taking any prescription medications? Yes No 19) Do you visit your doctor for annual check-ups? Yes No 20) Do you use mechanical devices such as: Wheelchair Yes No Walker Yes No Crutches Yes No Hospital bed Yes No Dialysis machine Yes No Oxygen Yes No Stairlift Yes No 21) Do you currently need or receive help in doing any of the following activities? Bathing Yes No Eating Yes No Dressing Yes No Toileting Yes No Transferring from bed to chair Yes No Maintaining Continence Yes No Within the past twelve months, have you… 22) Been confined to a nursing home Yes No 23) Custodial care facility Yes No 24) Received home health care services Yes No 25) Have you had any health symptoms relating to the conditions listed below? (If yes, please check the box next to the specific condition(s) listed below that you have been told you had or have been treated for) Select One Yes No Central Nervous System Skin, Bones or Muscles Mental Health, Drug Abuse Epilepsy Multiple Sclerosis Alzheimer's Disease Cancer Rheumatoid Arthritis Melanoma Cancer Alcoholism Drug Abuse Mental Illness Depression Digestive System Respiratory System Circulatory System Chronic Kidney Disease Liver Disease Kidney Stones Gastric/Peptic Ulcers Ulcerative Colitis or Ileitis Neurogenic Bladder Bowel Incontinence Diabetes Mellitus Cancer Asthma Emphysema Chronic Bronchitis COPD Cancer Coronary Artery Disease Vascular Disease High Blood Pressure Stroke Elevated Cholesterol Cancer HIV The answer to these basic questions will help us process your information and ensure that our search delivers the most competitive quote for your long term care insurance policy. 26) What range best describes your approximate household income: Select One Less than $25k $25-40k $41-60k $61-80k $81-100k $101-150k $151-200k $201-300k over $300k 27) Do you own or rent your residence: Select One Rent Own Other 28) Time at current residence: Select One Less than 1 Year 1-5 Years 5-10 Years 10-20 Years Over 20 Years 29) Please describe your credit history: Select One Major Problems Some Problems Good Some Lates Excellent Don't Know 30) Best Time To Contact: Select One Anytime Morning at Home Morning at Work Afternoon at Home Afternoon at Work Evening at Home Evening at Work Weekends 31) Additional Comments: Please provide any additional information you feel is pertinent to the insurance coverage you need. General Information: 1.  *First Name: 2.  *Last Name: 3.  *Phone: 4.  *Email: 5.  Address: 6.  Address: 7.  City: 8.  *State: Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutD.C.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 9.  *Zip Code: 9.  County: Site Map | Contact Info | Privacy | Terms & Conditions | Career | Referral | Help | Membership

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