LTC Preliminary Questionnaire

Long-Term Care Prescreen/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)

Aaron Clark

Darwin "DC" Couch

Joe Gordon

Other

Agent Information

Who is your referring Agent?(Required)

Referring Agent's Email(Required)

Referring Agent's Phone Number:(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 Country

Applicant Email Address(Required)

State of Residency:(Required)

Date of Birth:(Required)

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)

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 for insurance coverage?(Required)

If yes, which product type? (please select all that apply):(Required)

Life Insurance

Disability Insurance

Long-Term Care Insurance

Have you used Tobacco in the last 12 months?(Required)

If Yes, last date of use

Do you have a history of any of the following? (please select all that apply):(Required)

Date of Occurence

What type of Cancer were you diagnosed with?

What is the date treatment was completed?

What type of diabetes were you diagnosed with?

When were you diagnosed?

What was your last known A1C reading?

What is the date of onset?

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?

If yes, are you currently using it?

If yes, what type of procedure?

What was the outcome of the procedure?

If yes, what type?

What was the date of the procedure?

What was the date of last treatment?

Do you recieve more than 2 injections a year for your neck or back?

Have you had 2 or more prior back surgeries with ongoing chronic /recurrent back pain requiring treatment?

Have you been hospitalized in the last 5 years for depression?

Are you currently seeing a Psychiatrist?

If yes, what was the approximate date?

Any prescription medication taken during the past 2 years?(Required)

If Yes, please list the following: 1) Name of Medication(s) 2) dose of the medication 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?

Were two or more of your siblings or biological parents (FORMALLY) diagnosed with any type of Dementia?

Have you had a physical check-up with your health care provider in the last 2 years?(Required)

Is your Spouse interested in Long Term Care Coverage?(Required)

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)

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)

Have you previously been declined for insurance coverage?(Required)

If yes, which product type? (please select all that apply):(Required)

Life Insurance

Disability Insurance

Long-Term Care Insurance

Have you used Tobacco in the last 12 months?(Required)

If Yes, last date of use

Do you have a history of any of the following? (please select all that apply):(Required)

Date of Occurence

What type of Cancer were you diagnosed with?

What is the date treatment was completed?

What type of diabetes were you diagnosed with?

When were you diagnosed?

What was your last known A1C reading?

What is the date of onset?

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?

If yes, are you currently using it?

If yes, what type of procedure?

What was the outcome of the procedure?

If yes, what type?

What was the date of the procedure?

What was the date of last treatment?

Do you recieve more than 2 injections a year for your neck or back?

Have you had 2 or more prior back surgeries with ongoing chronic /recurrent back pain requiring treatment?

Have you been hospitalized in the last 5 years for depression?

Are you currently seeing a Psychiatrist?

If yes, what was the approximate date?

Any prescription medication taken during the past 2 years?(Required)

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?

Were two or more of your siblings or biological parents (FORMALLY) diagnosed with any type of Dementia?

Have you had a physical check-up with your health care provider in the last 2 years?(Required)

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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