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We only accept inquiries for insurance written in New York State

General Information
Name:
Address:
City:	State:   Zip:
Day Phone:	Night Phone:
Email Address:	Soc. Sec.#:
Date of Birth (mm/dd/yy):	Age:       Sex: M F
Height:	ft./in.       Weight: lbs.
Marital Status:	Married Single   If married, will spouse also apply for coverage? Y N   NOTE: If "YES", your spouse will need to complete a seperate form.

Current/Previous Insurance Information
Do you currently have another Long-Term Care insurance policy, rider or certificate (including health care service contract or health maintenance organization contract)?	Y   N
Did you previously have another Long-Term Care insurance policy, rider or certificate in force during the last 12 months? If so, when did it lapse (mm/dd/yy):	Y   N
Are you covered by a state assistance program (Medicaid)?	Y   N
Do you intend to replace any of your medical or health insurance coverage with this policy, rider or certificate?	Y   N
Are you now receiving long-term care or disability benefits?	Y   N
Have you ever been denied coverage for medical insurance, disability insurance, long-term care insurance, nursing home insurance, or life insurance? If "Yes", please explain below:	Y   N

Activities Information
Have you been confined to a hospital in the last 12 months?	Y   N
Has a physician recommended in the past 24 months that you be hospitalized or confined to a nursing facility, or that you have a surgical procedure?	Y   N
Have you consulted with a physician in the last 12 months for loss of appetite, falling, unstable gait, bladder or bowel control, dizziness or vision problems, or weight loss of 10 pounds or more?	Y   N
Do you need the help or supervision of another individual to perform your everyday living activities such as walking, dressing, eating, taking medications or tending to personal hygiene?	Y   N
Do you need the help or supervision of another individual to perform the independent activities of daily living such as handling your finances, doing laundry, shopping or using the telephone?	Y   N
Do you use any assistive devices such as a walker, wheelchair, crutches, cane, grab bars or any prescribed medical device or applicance? If "Yes", please explain below:	Y   N

Medical Information
If you answer "Yes" to any of the questions below, please use the text box at the end of this section to explain your answer.
In the past 5 years have you ever had, been told by a physician you had, or been treated for:
--osteoarthritis, osteoporosis, amputation, bone or joint disease, rheumatoid arthritis, or spinal stenosis?	Y    N
--internal cancer, tumor, leukemia, lymphoma, or Hodgkins disease?	Y   N
--disease of the kidney, stomach, liver, pancreas, or small or large intestine; or cirrhosis?	Y   N
--diabetes or thyroid disease?	Y   N
--disease of the lungs or respiratory system, emphysema, asthma, or shortness of breath?	Y   N
--disease of the heart or circulatory system, heart attack, high blood pressure or angina?	Y   N
--psychological, psychiatric or mental disorders, anxiety or depression?	Y   N
--neurological disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, stroke/TIA, paralysis, convulsions, epilepsy, seizures or muscular dystrophy?	Y   N
Have you been treated or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or have you tested positive for the HIV virus (as indicated by the results of the ELISA-ELISA Western blot test series)?	Y   N
Have you received medical advice, treatment or counseling relating to alcohol or drug abuse?	Y   N
If you answered "Yes" to any question in this section, please explain your answer(s) below:

Medication Information

Please list below any prescription medications that you are currently taking:

Additional Information
Do you have a valid drivers license and drive at least twice per week?	Y   N
Are you employed outside of the home or do you participate in any volunteer activities or organizations at least 8 hours per week?	Y   N
Have you used tobacco products within the past 12 months?	Y   N

Additional Comments

Please give any additional comments you feel appropriate for this quotation.

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