Long Term Care Worksheet

Instructions to complete and submit the worksheet:

Please use this worksheet to provide us with your information. Since this is a lot of information, please remember to click on the "Safe Info" button from time to time to avoid losing the information you have already entered.

All fields are required. You must enter NA if a question is not applicatble for you.

Click on the "Submit" button at the bottom of this screen once you have finished adding all the information in the form. The form submission will not be complete and we will not receive the information unless you click on the Submit button .

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Where is FUNDING (money) coming from?

You must answer all questions. Enter NA if not applicable

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Objectives: Primary Objective?

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Why LTC protection

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Medical Screening Questionnaire

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Medical Conditions – Please check all that apply:

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Check the boxes if any of the following medical conditions apply to you. If selected, you must complete all fields to provide related information.
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Current Medications (Daily usage of prescription narcotics are an automatic decline.)

Please list medications you are currently taking.. (Please include over-the-counter medications that are used daily)

Name of Medication
Dosage Amount
Condition
Start Date of Medication
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