To request a Personal Profile or receive more information regarding Long-Term Care Insurance, please complete and send us this questionaire. A representative will contact you at your convenience. This is a no obligation request. If you have any specific questions, feel free to enter them in the comments field provided and a representative will answer them.

All information will be kept confidential Your email address will NOT be sent, sold, or forwarded to anyone else. We respect your privacy. Contact Information Name: Address: City: State:       Zip: Phone Number: Email Address: Comments Enter your questions, comments, and/or a convenient time to contact you. We will be glad to answer them. Questions or comments? In order to provide you with a personal profile, the following information will need to be given. It's purpose is to help us provide you with accurate estimates to base your Long-term Care choices and decisions. All information will be kept confidential Personal Information Marital Status: Married    Single Your age: Have you had a complete routine Health exam within the past 2 years? Yes    No      Spouse: Yes    No Do you currently own a Long-term Care Insurance policy? Yes    No      Spouse: Yes    No Do you have any conditions that have made it difficult to obtain insurance? Yes    No      Spouse: Yes    No Have you smoked cigerettes in the last 5 years? Yes    No      Spouse: Yes    No Do you currently take any medications? If so, please include names of medications below Yes    No      Spouse: Yes    No Overall health condition: Please briefly describe yourself and your spouse's current prescribed medications and overall health Please include dates of hospitalization and brief reason(s) within the last 5 years If you currently own Long-term care, please describe your current benefits and when you purchased this plan. Thank you for taking the time to complete this form. These basic questions helps us to find coverage choices that will best suit your needs. A representative will contact you within the next 5 days to provide you with a personal profile and/or the answers to your questions.