Your Health Insurance Shop LTC Insurance Marketplace

First, let’s get to know each other. What’s your first name and your last name?
Perfect. What’s your email address?
We’ll use this to get in touch with you after the survey is completed. We promise not to spam you.
What’s your phone number?
Can we text you at that phone number?
No Yes
Date of birth
mm/dd/yyyy
Gender
Male Female
State of residence
Marital Status
Married Single Unmarried but in a commited relationship and living together at least 3 years
Is your spouse/partner interested in a quote?
No
Yes

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

Do you currently have or have you ever been diagnosed with any of the following?
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.

Is there a family history of Huntington’s Disease?
No Yes
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.
I have had testing to determine whether or not I have Huntington’s
No, I have not been tested for Huntington’s Yes, I had the testing and I am negative for Huntington’s

Any tobacco or nicotine use in the last 5 years? (Includes all delivery forms: smoking, gum, patch, pill, pouch, snuff, pray, e-cigarette, vapor, etc.)
No Yes

Please provide the date last used, frequency of use, and method of delivery (smoking, vaping, snuff, etc.)
Do you regularly consume 4 or more alcoholic beverages per day, or do you drink 5 or more drinks per day, 1 or more days per week?
No Yes

Please provide details.
Do you use marijuana or CBD, whether for recreation or prescribed?
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.
Have you ever received or been advised to have counseling for alcohol or drug abuse?
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.

Have you been diagnosed with Diabetes or pre-Diabetes?
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.
Have you been diagnosed with Rheumatoid Arthritis or Osteoarthritis?
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?
Have you ever had a Stroke, TIA or CVA?
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.

Have you ever been diagnosed with Osteoporosis?
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?
Have you ever been diagnosed with Cancer?
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.

Have you ever been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) or Emphysema?
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.

Has any of these biological relatives been diagnosed with Alzheimer’s or other forms of dementia?
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?

Do you have a handicap placard/license plate for your personal use?
No Yes

If yes, please indicate reason
Are you currently receiving disability benefits?
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.

Do you take any prescription medications?
No Yes
List prescribed medication. Explain what they treat, dosage, how often you take them, and approximate date that they were first prescribed (month/year is ideal, but if unknown, approximate year is fine)

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
Are there medications prescribed in the last two years that you no longer take? (exclude medications for cold/flu)
No Yes

Provide name of medication, why prescribed, and when you last took it
Any steroid or cortisone injections in the last 2 years?
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?
Do you have any other medical conditions that we have not mentioned, or is there anything else you’d like us to know?
No Yes

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

One last thing, not about your health. What has motivated you to look into long term care insurance today?

Thank you!

About You