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LTC Preliminary Questionnaire

Home/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)

Agent Information

Applicant Information

Applicant Name(Required)
Applicant Address(Required)
MM slash DD slash YYYY
Gender(Required)
What is your total approximate household Income?(Required)
Approximate total assets and investments NOT including your home:(Required)

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.

If yes, which product type? (please select all that apply):(Required)
MM slash DD slash YYYY
Do you have a history of any of the following? (please select all that apply):(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
What is the severity of your sleep apnea? (please select one option below)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Medication List
Exact name of Medication
Strength (Ex. 25mg or .05%)
Frequency (Ex. 2 per day)
Reason Prescribed (Ex. Blood Pressure)
 
MM slash DD slash YYYY
MM slash DD slash YYYY

Applicant Information (Second Applicant)

Applicant Name(Required)
MM slash DD slash YYYY
Gender(Required)
What is your total approximate household Income?(Required)
Approximate total assets and investments NOT including your home:(Required)
If yes, which product type? (please select all that apply):(Required)
MM slash DD slash YYYY
Do you have a history of any of the following? (please select all that apply):(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
What is the severity of your sleep apnea? (please select one option below)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
If you got sick and needed Long Term Care which asset would you liquidate first to pay for it? (Please select one)(Required)
Consent

About Us

OCI

Headquartered in Elkhorn, Nebraska, OCI Insurance & Financial Services, Inc., is an insurance general agency providing support to thousands of agents nationwide in the placement of these products and services.

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OCI Insurance & Financial Services, Insurance Agency, Elkhorn, NE

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Contact Us

402.330.8700
Toll free: 866.320.8700
Fax: 402.330.8706

4221 N. 203rd St, Ste 200
Elkhorn, NE 68022

Hours:
Monday – Thursday: 8:00 am – 5:00 pm
Friday: 8:00 am – 4:30 pm

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