GTL Home Care Secure

Please complete all sections, then select Submit at the bottom of the final page.

25% of survey complete.

NEXT STEP: Complete this health questionnaire so we may determine your eligibility to apply.

Estimated 2 to 4 minutes to complete.
Simply close your browser if you want to stop and not submit your answers.

- This is NOT an application for insurance. This information is used to determine your eligibility to apply for a policy. If you qualify, we will contact you and when you are ready, assist you with submitting an electronic application.

- Health information is ONLY used to assess your eligibility for insurance.
- One questionnaire per person. You may complete for someone else if familiar with their health history.
- Questions? 855-204-1214

This Questionnaire is HIPAA compliant.

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Question Title

* 1. What coverage amount was of greatest interest to you?

Plan A: More Affordable. $20,000 face amount

Plan B: Most Popular. $30,000 face amount

Plan C: More Coverage. $60,000 face amount

Unsure. Let's discuss.

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* 2. State of residence (Product available only in listed states)

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* 3. What is your Date of Birth (MM/DD/YYYY)? Product available for ages 35-84

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* 4. Within the past 12 months
- have you been diagnosed as having, been prescribed medication for or been treated by a member of the medical profession for Alzheimer's disease, dementia, multiple sclerosis, Parkinson's disease, cancer, heart disease, stroke or kidney failure?
- have you required Home Health Care, Skilled Nursing services, Adult Day Care or had a Nursing Home stay?
- have you required assistance in performing Activities of Daily Living; bathing, continence, dressing, eating, toileting, or transferring.
- have you required a wheelchair, 4-prong cane, walker, hospital bed or motorized care?
- have you required physical, occupational, or speech therapy?

Yes