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Long Term Care Insurance -
              Prequalification Questionnaire

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?
  


 
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