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LTC Preliminary Questionnaire
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LTC Preliminary Questionnaire
Long-Term Care Prescreen/Preliminary Questionnaire
Long-Term Care Preliminary Questionnaire
Thank you for the opportunity for us to assist you with your Long-Term Care planning needs. If you complete this form, we will use the information to submit a preliminary assessment with the Long-Term Insurance Companies to determine potential eligibility and estimated rates.
Are you working with an OCI Team member currently? (Please pick 1, if no one select other)
(Required)
Aaron Clark
Darwin "DC" Couch
Joe Gordon
Other
Agent Information
Agent's Email
(Required)
Agent's Phone Number:
(Required)
Who is your Agent?
(Required)
Applicant Information
Applicant Name
(Required)
First
Last
Applicant Phone Number
(Required)
Applicant Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Applicant Email Address
(Required)
State of Residency:
(Required)
Date of Birth:
(Required)
MM slash DD slash YYYY
Height:
(Required)
Weight:
(Required)
Gender
(Required)
Male
Female
What is your total approximate household Income?
(Required)
Under $50,000
$50,001-$75,000
$75,001-$125,000
$125,001-$225,000
$225,001+
Approximate total assets and investments NOT including your home:
(Required)
Under $50,000
$50,001-$100,000
$100,001-$350,000
$350,001-$500,000
$500,001-$1,000,000
$1,000,001+
What is the primary reason/goal you are requesting Long-Term Care coverage?
(Required)
Are you receiving or have you received any disability insurance benefits or social security disability benefits?
(Required)
No
Yes
What are you willing to set aside for a "premium commitment" on a monthly basis to address your LTC needs?
(Required)
$1,500-3,000
$3,000-$5,000
$5,000-$10,000
$10,000+
LTCi Average Cost of Care
Based on the information provided. You are not eligible and can stop filling out the form here
If NO, please continue filling out the form.
Have you previously been declined or rated for Long Term Care, Life, or Disability Insurance? (Yes or No)
(Required)
No
Yes
When and what insurance type were you declined or rated for? (Long Term Care, Life, or Disability)
Do you have a Long Term Care Insurance plan in force now? (Yes or No)
No
Yes
Do you plan to replace your policy if a new one is approved?
No
Yes
If yes, which product type? (please select all that apply):
(Required)
Life Insurance
Disability Insurance
Long-Term Care Insurance
Select All
Have you used Tobacco in the last 12 months?
(Required)
No
Yes
If Yes, last date of use
MM slash DD slash YYYY
Do you have a history of any of the following? (please select all that apply):
(Required)
Cancer
Diabetes
Sleep Apnea
Coronary Artery Disease
Neck or Back Disorder
Depression and/or Anxiety
Immune System Disease
Balance/Gait Impairment
Surgery or Medical Procedures in last 10 years
Scheduled procedures, tests, or surgeries that have not been completed yet
Heart Attack
Stroke
Any other medical concerns not listed above
None of the Above
Select All
Date of Occurence
MM slash DD slash YYYY
Date of Occurence
MM slash DD slash YYYY
What type of Cancer were you diagnosed with?
What is the date treatment was completed?
MM slash DD slash YYYY
What type of diabetes were you diagnosed with?
When were you diagnosed?
MM slash DD slash YYYY
What was your last known A1C reading?
What is the date of onset?
MM slash DD slash YYYY
What is the severity of your sleep apnea? (please select one option below)
Mild
Moderate
Severe
Have you been prescribed a Cpap machine, BiPAP, or dental device to use?
No
Yes
If yes, are you currently using it?
No
Yes
If yes, what type of procedure?
What was the outcome of the procedure?
If yes, what type?
What was the date of the procedure?
MM slash DD slash YYYY
What was the date of last treatment?
MM slash DD slash YYYY
Do you recieve more than 2 injections a year for your neck or back?
No
Yes
Have you had 2 or more prior back surgeries with ongoing chronic /recurrent back pain requiring treatment?
No
Yes
Have you been hospitalized in the last 5 years for depression?
No
Yes
Are you currently seeing a Psychiatrist?
No
Yes
If yes, what was the approximate date?
MM slash DD slash YYYY
What is the name of your immune system disease?
What date were you diagnosed?
MM slash DD slash YYYY
Any prescription medication taken during the past 2 years?
(Required)
No
Yes
Medication List
Exact name of Medication
Strength (Ex. 25mg or .05%)
Frequency (Ex. 2 per day)
Reason Prescribed (Ex. Blood Pressure)
Add
Remove
Please list your most significant medical event during your lifetime?
Date of last cardiac test?
MM slash DD slash YYYY
Were two or more of your siblings or biological parents (FORMALLY) diagnosed with any type of Dementia?
No
Yes
Have you had a physical check-up with your health care provider in the last 2 years?
(Required)
No
Yes
If yes, what was the approximate date?
MM slash DD slash YYYY
Are you Single or Married?
Single
Married
Is your Spouse interested in Long Term Care Coverage? (NOTE: Discounts may apply when both apply for coverage**)
(Required)
No
Yes
Applicant Information (Second Applicant)
Applicant Name
(Required)
First
Last
Applicant Phone Number
(Required)
Applicant Email Address
(Required)
State of Residency
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Height
(Required)
Weight
(Required)
Gender
(Required)
Male
Female
What is your total approximate household Income?
(Required)
Under $50,000
$50,001-$75,000
$75,001-$125,000
$125,001-$225,000
$225,001+
Approximate total assets and investments NOT including your home:
(Required)
Under $50,000
$50,001-$100,000
$100,001-$350,000
$350,001-$500,000
$500,001-$1,000,000
$1,000,001+
What is the primary reason/goal you are requesting Long-Term Care coverage?
(Required)
Are you receiving any disability insurance benefits?
(Required)
No
Yes
Have you previously been declined for insurance coverage?
(Required)
No
Yes
If yes, which product type? (please select all that apply):
(Required)
Life Insurance
Disability Insurance
Long-Term Care Insurance
Select All
Have you used Tobacco in the last 12 months?
(Required)
No
Yes
If Yes, last date of use
MM slash DD slash YYYY
Do you have a history of any of the following? (please select all that apply):
(Required)
Cancer
Diabetes
Sleep Apnea
Coronary Artery Disease
Neck or Back Disorder
Depression and/or Anxiety
Immune System Disorders
Balance/Gait Impairment
Surgery or Medical Procedures in last 10 years
Scheduled procedures, tests, or surgeries that have not been completed yet
Heart Attack
Stroke
Any other medical concerns not listed above
None of the Above
Select All
Date of Occurence
MM slash DD slash YYYY
Date of Occurence
MM slash DD slash YYYY
What type of Cancer were you diagnosed with?
What is the date treatment was completed?
MM slash DD slash YYYY
What type of diabetes were you diagnosed with?
When were you diagnosed?
MM slash DD slash YYYY
What was your last known A1C reading?
What is the date of onset?
MM slash DD slash YYYY
What is the severity of your sleep apnea? (please select one option below)
Mild
Moderate
Severe
Have you been prescribed a Cpap machine, BiPAP, or Dental device to use?
No
Yes
If yes, are you currently using it?
No
Yes
If yes, what type of procedure?
What was the outcome of the procedure?
If yes, what type?
What was the date of the procedure?
MM slash DD slash YYYY
What was the date of last treatment?
MM slash DD slash YYYY
Do you recieve more than 2 injections a year for your neck or back?
No
Yes
Have you had 2 or more prior back surgeries with ongoing chronic /recurrent back pain requiring treatment?
No
Yes
Have you been hospitalized in the last 5 years for depression?
No
Yes
Are you currently seeing a Psychiatrist?
No
Yes
Any prescription medication taken during the past 2 years?
(Required)
No
Yes
If Yes, please list the following: 1) Name of medication(s) 2) dose of medication(s) 3) reason it was prescribed. Please list ALL 3 for each prescription.
(Required)
Please list your most significant medical event during your lifetime?
Date of last cardiac test?
MM slash DD slash YYYY
Were two or more of your siblings or biological parents (FORMALLY) diagnosed with any type of Dementia?
No
Yes
Have you had a physical check-up with your health care provider in the last 2 years?
(Required)
No
Yes
If you got sick and needed Long Term Care which asset would you liquidate first to pay for it? (Please select one)
(Required)
Checking/Savings Account(s)
Investments
Old Annuities
IRA/401K
Consent
By checking the box you are certifying that the information completed on this form is factual to your knowledge. You are giving OCI Insurance consent to submit a preliminary assessment with the Long Term Companies to determine potential eligibility and estimated rates.
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