Neilson Insurance Services Inc.

Long Term Care Quote Request

Fill in the form below to receive an long term care product quote.
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Fields marked with * are required. Tab through questions, do NOT hit enter or incomplete form will be submitted.

Client Information
Name
Birthdate	/ /
Use Tobacco	yes no
Height & Weight	' '' & lbs.
Spouse Name
If applying jointly, please complete separate form.
*Health History If yes, please describe**
Are you currently using oxygen, a wheelchair, crutches, or a quad cane?
no yes
Do you receive help bathing; eating; dressing; or transferring?
no yes
Do you currently have, or have you ever had a diagnosis for symptoms of Alzheimer's disease, dementia, loss of memory, or multiple sclerosis, muscular dystrophy, Lou Gehrig's Disease, or Parkinson's?
no yes
Have you recently been under a doctor's care for any health conditions?
no yes
Have been hospitalized, advised or had surgery, medical care, EKG, x-ray, diagnostic test within the last five (5) years or plan surgery in 6 months?
no yes
Within the last 5 years have you received medical advice from a member of the medical profession for any of the following:
High blood pressure, chest pain, irregular heart beat, coronary artery disease, or other heart or circulatory system diseases?
no yes
Polyp, benign tumor, leukemia, lymphoma, cancer, or a disorder of the immune system?
no yes
Diabetes, or any glandular or thyroid disease or disorder?
no yes
Any disorder of intestines, liver, stomach or digestive system?
no yes
Mental disorder, anxiety, depression, alcohol abuse, drugs addiction, or any psychological or emotional condition or disorder?
no yes
Arthritis, osteoporosis, any chronic pain condition, or any other disease or disorder of the back, spine, joints, muscles or neck?
no yes
Shortness of breath or any disorder of the respiratory system?
no yes
Dizziness, imbalance, or any disorder of the eyes or ears?
no yes
Seizures, stroke, or any disorder of the brain or nervous system?
no yes
What prescription medications do you take on a regular basis? none
Name Daily Dosage
Name Daily Dosage
Name Daily Dosage
Name Daily Dosage
Name Daily Dosage