If you have any questions about your benefit plans, please don't hesitate to or call Kristen Garry at 267.794.3010.

To learn more about Gallagher Benefit Services visit tccgroup.com.

To learn more about the Cultural Alliance visit philaculture.org

Individual Long Term Care

Insurance Questionnaire

(All Information is Confidential)

To furnish the appropriate product and quotation for you at the potentially lowest possible cost, please complete the following questionnaire. * denotes a required field.

I. Your Information

Name *

Company

Phone *

E-mail *

 

II. Coverage Design Questions
All proposals will provide coverage for home health care, intermediate care and nursing home care.

1.

What amount of daily coverage is needed?

$100   $130   $150   $200   $250  

2.

When should benefits begin?

20 days   60 days   90 / 100 days

3.

Is an automatic inflation adjustment important to you?

Yes   No

If Yes...

5% simple increase
5% compound annual increase

4.

How long should benefits continue?

2 years   3 years   5 years  
6 years   Lifetime Benefits

5.

Several policies provide a paid up benefit for a surviving spouse in the event of death. Is a pre-funded survivor benefit important to you?

Yes   No

 

III. Personal Profile Questions

1.

Marital Status

Single   Married

2.

Date of Birth

   

3.

Spouse Date of Birth (if applicable)

  

4.

Do you participate in a regular fitness program?

Yes   No

5.

Have you applied for any other insurance program during the past three years that was issued preferred?

Yes   No   N/A

 

IV. Medical History Qualification Questions

1.

Do you use any of the following?

Walker or Wheelchair ... Oxygen ... Respirator ... Kidney Dialysis

Or need assistance or supervision by another person performing any of the following?
Moving in / out of bed or chair ... Bathing ... Dressing ... Eating ... Toileting ... Bowel / Bladder Control ... Walking

Yes   No

2.

Have you had, do you currently have, or have you ever been medically diagnosed as having any of the following?

ALS (Lou Gehrigs Disease) or Alzheimer's Disease

Frequent or Persistent Forgetfulness ... Memory Loss ... Metastatic Cancer (spread from original site/location) ... Multiple Sclerosis (MS) ... Muscular Dystrophy ... Organic Brain Syndrome ... Parkinson's Disease ... Senility ... Stroke ... Transient Ischemic Attack (TIA) with in the past 5 years ... TIA in combination with diabetes or Heart Surgery ... TIA two or more times

Congestive Heart Failure (CHF) in combination with any of the following:
Heart Attack or Angina ... Emphysema / Chronic Obstructive Pulmonary Disease (COPD) ... Angioplasty or Heart Surgery ... Asthma or Chronic Bronchitis ... Diabetes or Tuberculosis (TB) ... Cirrhosis of the Liver ... Dementia ... Diabetes under treatment with insulin

Emphysema/COPD in combination with any of the following:
current smoking ... Congestive Heart Failure (CHF) ... Asthma ... Chronic Bronchitis

Yes   No

4.

Have you ever been diagnosed by a member of the medical profession as having...

Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?

Yes   No

5.

In the past 4 years have you had Cancer of the...

Bone ... Brain ... Esophagus ... Liver ... Ovary ... Pancreas ... Stomach ... Testes

Yes   No