The following questionnaire will help you determine eligibility for long-term care insurance coverage. All companies have slightly different rating criteria, so even though you may not be eligible for coverage through a carrier we write with, you may be eligible through another long-term insurance carrier.

DO NOT APPLY IF YOU ANSWER "YES" TO ANY OF THE FOLLOWING QUESTIONS.

Do you currently have or have you ever had a diagnosis for:

Alzheimer's	Amyotrophic Lateral Sclerosis
Cerebal Atrophy	Cirrhosis
Cystic Fibrosis	Crest
Dementia	TIA- 2 or more (Transient Ischemic Attack)
Kidney Failure	Memory Loss
Mental Retardation	Metastasis Cancer
Mixed Connective Tissue Disease	Multiple Sclerosis
Muscular Dystrophy	Neurological conditions- Affecting the brain or spinal cord.
Multiple Myeloma	Parkinson's
Organic Brain Syndrome	Schizophrenia
Post Polio Paralytic Syndrome	Spinal Cord Injury
Myasthenia Gravis	Stroke/CVA- Cardiovascular Attack
Scleroderma

Do you require human assistance or supervision in any of the following activities?

Eating	Dressing
Toileting	Walking
Bathing	Maintaining Continence
Transferring from bed to chair

Do you currently reside in, have you been advised to enter, are you planning to enter a nursing home, assisted care living facility or other custodial facility, or are you currently receiving home health care services or attending adult day care?

Do you currently use one of the following medical devices?

Wheelchair	Walker
Hospital Bed	Quad Cane
Oxygen	Stair Lift
Dialysis

Have you ben diagnosed or treated by a member of the medical profession for AIDS (Acquired Immune Deficiency Syndrome) or AIDS Related Complex?

Are you currently receiving Social Security disability benefits?