Please complete as much of the following as you can at this time. Thank you.

Have you used any type of tobacco product within the past 5 years?
   Yes No        Spouse:Yes No

Do you or your spouse drive an automobile?
   Yes No        Spouse:Yes No

What is the one main reason for your purchase of long term care insurance protection?

Additional Comments:

Have you or your spouse ever been declined for long term care insurance?
   Yes No       Spouse:Yes No

Do you intend to enroll in a policy within the next 90 days? 
   Yes No

Do you already own a long term care insurance policy, or have you talked
to any insurance agents to get quotes for long term care coverage?
   Yes No

Please name the long term care insurance carriers you are
already covered by or have received quotes from:

Applicant Health:

Spouses Health:

Is this inquiry for your parents?      Yes No
If so, in what state do they reside? State:

Are you affiliated with any company or association? If yes, name of company or association:    

LEGAL NOTICE to INSURANCE AGENTS: Mandatory Full Disclosure: Are you involved in any way in the sale of LTC insurance, or are you currently licensed to sell LTC insurance in any state?    Yes No
If yes, click here now and do not submit this form.