The following questionnaire will help you determine eligibility for long-term care insurance coverage. All companies have slightly different rating criteria, so eligibily requirements may differ with the various providers.

If you answer "yes" to any of the questions below, do not request a quote.

ELIGIBILITY QUESTIONNAIRE

Do you currently have or have you ever had a diagnosis for:
Alzheimer's Cerebral Atrophy Cystic Fibrosis Dementia Kidney Failure Mental Retardation Mixed Connective Tissue Disease Muscular Dystrophy Multiple Myeloma Organic Brain Syndrome Post Polio Paralytic Syndrome Scleroderma Myasthenia Gravis	Amyotrophic Lateral Sclerosis Cirrhosis Crest TIA (transient ischemic attack) - 2 or more Memory Loss Metastasis Cancer Multiple Sclerosis Neurological conditions - affecting brain or spinal cord Parkinson's Schizophrenia Spinal Cord Injury Stroke/CVA
Do you require human assistance or supervision in any of the following activites?
Eating Walking Dressing Bathing	Maintaining continence Toileting 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 reeiving home health care services or attending adult day care?
Do you currently use one of the following medical devices?
Wheelchair Hospital bed Oxygen Dialysis	Walker Quad cane Stair lift
Have you been diagnosed or treated by a member of the medical profession for AIDS (Aquired Immune Deficiency Syndrome) or AIDS Related Complex?
Are you currently receving Social Security disability benefits?