APPLICANT INFORMATION
First Name:
Last Name:
Street Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP Code:
Home Phone:
Work Phone:
E-Mail Address:
Date of Birth:	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Sex:	Male    Female
Height:	4 5 6 4 7 feet    0 1 2 3 4 5 6 7 8 9 10 11 inches
Weight:	Please select Up to 100 100-110 110-120 120-130 130-140 140-150 150-160 160-170 170-180 180-190 190-200 200-210 210-220 220-230 230-240 240-250 250+
Marital Status:	Please select Single Married Separated Divorced Widowed Domestic Partner
If married, will spouse apply for coverage?
Yes    No
NOTE: If 'Yes', your spouse will need to complete a separate form.
PRIOR INSURANCE INFORMATION
Do you currently have another Long-Term Care insurance policy, rider, or certificate (including health care service contract or HMO)?			Yes    No
Did you previously have another Long-Term Care insurance policy, rider, or certificate in force during the last 12 months?			Yes    No
If so, when did it lapse?		January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Are you covered by a state assistance program (Medicaid)?			Yes    No
Do you intend to replace any of your medical or health insurance coverage with this policy, rider or certificate?			Yes    No
Are you now receiving long-term care or disability benefits?			Yes    No
Have you ever been denied coverage for medical insurance, disability insurance, long-term care insurance, nursing home insurance, or life insurance?			Yes    No
If 'Yes', please explain:
ACTIVITIES INFORMATION
Have you been confined to a hospital in the last 12 months?			Yes    No
Has a physician recommended in the past 24 months that you be hospitalized or confined to a nursing facility, or that you have a surgical procedure?			Yes    No
Have you consulted with a physician in the last 12 months for loss of appetite, falling, unstable gait, bladder or bowel control, dizziness, or vision problems?			Yes    No
Do you need the help or supervision of another individual to perform your everyday living activities such as walking, dressing, eating, taking medication?			Yes    No
Do you need the help or supervision of another individual to perform the independent activities of daily living such as handling your finances, doing household chores, etc.?			Yes    No
Do you use any assistive devices such as a walker, wheelchair, crutches, cane, grab bars or any prescribed medical device or applicance?			Yes    No
If 'Yes', please explain:
MEDICAL INFORMATION
In the past 5 years have you been diagnosed with, or been treated for:
Osteo arthritis, osteoporosis, amputation, bone or joint disease, rheumatoid arthritis, or spinal stenosis?			Yes    No
Internal cancer, tumor, leukemia, lymphoma, or Hodgkins disease?			Yes    No
Disease of the kidney, stomach, liver, pancreas, or small or large intestine; or cirrhosis?			Yes    No
Diabetes or thyroid disease?			Yes    No
Disease of the lungs or respiratory system, emphysema, asthma, or shortness of breath?			Yes    No
Disease of the heart or circulatory system, heart attack, high blood pressure or angina?			Yes    No
Psychological, psychiatric or mental disorders, anxiety or depression?			Yes    No
Neurological disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, stroke/TIA, paralysis, convulsions, epilepsy, seizures, etc.?			Yes    No
Have you been treated or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or have you tested positive for HIV?			Yes    No
Have you received medical advice, treatment or counseling relating to alcohol or drug abuse?			Yes    No
If you answered 'Yes' to any question in this section, please explain your answer(s):
Please list any prescription medications that you are currently taking:
ADDITIONAL INFORMATION
Do you have a valid drivers license and drive at least twice per week?			Yes    No
Are you employed outside of the home or do you participate in any volunteer activities or organizations at least 8 hours per week?			Yes    No
Have you used tobacco products within the past 12 months?			Yes    No
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