Long-Term Care Insurance - Preliminary Health Screen

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Health Questionnaire Information

The next step in exploring Long-Term Care Insurance is to complete this online and secure health questionnaire. This questionnaire takes from 5-15 minutes to complete.

Long-term care insurance is medically underwritten. This means that your health history can influence the solutions that your advisor will have available for you.

We will review your submitted questionnaire and let your advisor know which solutions you are likely eligible to pursue. We will contact you if we need clarification on a particular item.

Please Note:

- This is not an application for insurance. It is a step in the process before completing a formal application.
- Have your medication information handy. It will help you complete the questionnaire faster.
- This questionnaire is HIPAA compliant. Your medical information will not be shared with any third parties.
- If a spouse or partner is interested in this coverage, they need to complete a separate questionnaire.

Please be as thorough as possible.

Questions?
Call us at 877-949-4582 and ask for assistance with the Underwriting Partner Questionnaire.

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Question Title

* 1. Is it okay if we share detailed results with your advisor?

Yes

Answering "Yes" allows us to share specific health history reasons why you may not qualify or reasons why you may qualify at a particular rate classification. Answer "No" if you do not want us to share this information with your advisor.
Regardless of the answer to this question, your advisor will be notified you submitted this prescreen and we will advise them whether or not you likely qualify.