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Honest and complete health information helps you receive a more accurate quote.
This information is used only to assist you with this insurance. 

When we receive your questionnaire we will:

Review the information to confirm your likely eligibility.

Review our options to shop for the best value.

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Section 1

About You

  2. We’ll use this to get in touch with you after the survey is completed. We promise not to spam you.

  4. No Yes

  5. mm/dd/yyyy

  6. Male Female
  8. Married Single Unmarried but in a commited relationship and living together at least 3 years
  9. No
    Yes

    If yes, enter their first and the last name. They will need to complete their own health questionnaire.

  1. Alzheimer’s Disease, Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig’s Disease), Congestive Heart Failure, Cystic Fibrosis, Dementia, Huntington’s Chorea, Memory Loss, Mental Retardation, Multiple Myeloma, Multiple Sclerosis, Muscular Dystrophy, Myasthenia Gravis, Parkinson’s Disease, Schizophrenia, or Spinal Cord Injury.

    and/or

    Acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC).

    and/or

    Do you currently need assistance with bathing, dressing, or mobility, including using a cane, crutch or walker?

    No Yes

    Your answer indicates you are ineligible for a long-term care insurance policy. Contact us at (855) 204-1214 or email us at mpg@ltcipartners.com if you would like to review this. Please do not continue or submit this questionnaire.

  1. No Yes
  2. No Yes

    Your answer indicates you are ineligible for a long-term care insurance policy. Contact us at (855) 204-1214 or email us at mpg@ltcipartners.com if you would like to review this. Please do not continue or submit this questionnaire.

  3. No Yes

    Your answer indicates you are ineligible for a long-term care insurance policy. Contact us at (855) 204-1214 or email us at mpg@ltcipartners.com if you would like to review this. Please do not continue or submit this questionnaire.

  4. No Yes

    Your answer indicates you are ineligible for a long-term care insurance policy. Contact us at (855) 204-1214 or email us at mpg@ltcipartners.com if you would like to review this. Please do not continue or submit this questionnaire.

  5. No Yes

    Your answer indicates you are ineligible for a long-term care insurance policy. Contact us at (855) 204-1214 or email us at mpg@ltcipartners.com if you would like to review this. Please do not continue or submit this questionnaire.

  1. No Yes

  2. The types of coverage options available for individuals with a family history of Huntington’s Disease will depend on whether or not you have had the specific testing to determine you do not have Huntington’s.

    • Answer NO if you have not been tested. Continue with this questionnaire (we may still have options for insuring you).
    • Answer YES if you have been tested and are negative for Huntington’s. Continue with the questionnaire.

    If you have had the testing and are positive for Huntington’s, unfortunately we do not have any insurance options available to you. You can close this window and your responses will not be saved.

    No, I have not been tested for Huntington’s Yes, I had the testing and I am negative for Huntington’s

  1. Height format 5’ 2” (first box) / Weight in pounds (second box)

  2. No Yes

    If you are age 60 or older, one may be needed as some insurance companies rely on the results of your last physical. We will let you know if you will need to schedule a physical with your doctor to be eligible to apply for coverage.

  3. No Yes

    Please provide the reading or approximate reading

  4. No Yes

    Please provide details such as a diagnosis or if a cold, flu, Covid-19, allergies, etc.

  5. No Yes

    Please provide details.

  6. No Yes

    Include reasons and approximate date (month/year if in the last 24 months or just the year if over 24 months ago).

  7. No Yes

    Explain the medical condition, the recommended or completed treatment, when it began/is scheduled to begin, and when it ended/is scheduled to end.

  8. No Yes

    Please provide the following THREE details as best you recall: (1) the name of the insurance company (2) the reason you were declined (3) the year you were declined.

  9. No Yes

    Please indicate approximate month/year, the type of specialist, and the reason for the visit.

  1. No Yes

    Please provide the date last used, frequency of use, and method of delivery (smoking, vaping, snuff, etc.)

  2. No Yes

    Please provide details.

  3. No Yes

    Provide all of the following THREE items (1) explain if recreational or prescribed and if prescribed, the condition it treats (2) frequency of use (3) method(s) of ingestion.

  4. No Yes

    Provide the following TWO details. (1) which type of counseling (2) whether currently receiving it, and if not currently receiving it, the time frame it was received.

  1. No Yes

    Please provide ALL of the following: (1) Type of therapy (2) What condition it treated (3) When therapy began (4) When it ended or is scheduled to end.

  2. No Yes

    Please specify your diagnosis and what treatments you have received.

  3. No Yes

    Please provide details.

  4. No Yes

    Please specify if DISCOID or SYSTEMIC and the date of diagnosis (month/year if in the last 24 months or just the year if over 24 months ago)

  5. No Yes

    Provide the diagnosis, date of diagnosis (month/year if in last 12 months; otherwise, the year), and explain how it was treated or currently is being treated.

  6. No Yes

    Please provide all FOUR of the following: (1) Year you were diagnosed (2) Year of your last sleep study (3) Is your Sleep Apnea considered Mild, Moderate, or Severe, (4) How is it being treated? (CPAP, BIPAP, oxygen, something else?)

  7. No Yes

    Please provide the following: (1) Specific Diagnosis (2) Year diagnosed (3) Treatments you received (4) Current treatments

  8. No Yes

    Please provide details.

  9. No Yes

    Indicate ALL the following. (1) Diagnosis. (2) Whether any medications types or dosages have been changed in the last 12 months (3) If any, dates of any hospitalizations due to the condition. (4) If any, dates of any suicide attempts.

  1. No Yes

    Please provide all FIVE of the following: (1) Whether Type 1 or Type 2 (2) Approximate year you were diagnosed (3) Your most recent A1C reading (4) Share whether your current A1C is higher, lower, or stable compared to other recent readings (5) Indicate if any history of neuropathy, nephropathy, or retinopathy.

  2. No Yes

    Please provide all FOUR of the following: (1) Which joints involved (2) Any limitations in physical activity? (3) Any joint replacements? (4) Any fractures?

  3. No Yes

    Please provide all THREE of the following: (1) Indicate whether it was a Stroke, TIA, or CVA (2) Include the month/year it occurred including month/year of any recurrences (3) Indicate whether you have any physical limitations as a result.

  1. No Yes

    Provide ALL of the following FIVE details: (1) Date of diagnosis (month/year if within last year, otherwise, year). (2) T-scores from your last bone density, as best you can remember. (3) Which bones are involved? (4) Whether you have had any fractures or falls. (5) Indicate if any joint replacements completed or recommended?

  2. No Yes

    Please provide all THREE of the following: (1) Year diagnosed (include month if in last 24 months) (2) Stage (3) Treatment you received (4) Any recurrences? (5) For skin cancers, indicate if basal cell, squamous cell, or the stage of melanoma.

  1. No Yes

    Please provide ALL of the following THREE details: (1) Is your diagnosis COPD or Emphysema? (2) Explain frequency of use of any or all of oxygen, IPPB therapy, or home respiratory therapy (3) Indicate whether there are activities restricted due to shortness of breath.

  1. Mother Father Both Parents One Sibling Two or more siblings Combination of one or more parents and one or more siblings None of these

    What was the approximate age of onset for their condition?

    What was the approximate age of onset for their condition?

    What was the approximate age of onset for their condition?

    What was the approximate age of onset for their condition?

    What was the approximate age of onset for their condition?

    What was the approximate age of onset for their condition?

  1. No Yes

    If yes, please indicate reason

  2. No Yes

    Indicate whether it is VA (include percentage), social security, or other disability benefits, Indicate reason and approximate year you qualified for disability benefits.

  1. No Yes

  2. Medication 1 name and condition it treats

    Medication 1 dosage and date originally prescribed

    Medication 2 name and condition it treats

    Medication 2 dosage and date originally prescribed

    Medication 3 name and condition it treats

    Medication 3 dosage and date originally prescribed

    Medication 4 name and condition it treats

    Medication 4 dosage and date originally prescribed

    Medication 5 name and condition it treats

    Medication 5 dosage and date originally prescribed

    Medication 6 name and condition it treats

    Medication 6 dosage and date originally prescribed

    Medication 7 name and condition it treats

    Medication 7 dosage and date originally prescribed

  3. No Yes

    Provide name of medication, why prescribed, and when you last took it

  4. No Yes

    Please provide ALL of the following FOUR details: (1) Explain what condition they treated (2) the number of injections (3) Date of last injection (4) Are more injections planned?

  5. No Yes

    Provide information such as names, dates, and types of diagnoses and treatments.

About You - 0 of 9 answered