WGG - Disability Introduction

Long Term Care Quote:

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LONG-TERM CARE QUOTE REQUEST
Please complete the following information if you would like to obtain a quote on Long-Term Care Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
What is your Name?	Last Name
What is your Name?	First Name
What is your email address?	e-mail
What is your Address?	Street
	City
	State
	Zip
What is your Telephone Numnber?	Daytime
	Evening
	Mobile
What is your Gender	Gender	Male Female
What is your Height	Feet plus inches (example 5'8)
What is your Weight	Weight
Are you married?	Yes No	Spouse's Birthdate
Fill in spouse if spouse is also applying
	Self	Spouse
Do you smoke?	Yes No	Yes No
Are you diabetic?	Yes No	Yes No
Are you insulin dependent?	Yes No	Yes No
Do you use a cane?	Yes No	Yes No
Do you use a walker?	Yes No	Yes No
Do you use a wheel chair?	Yes No	Yes No
Do you use any other equipment?	Yes No	Yes No
If you have required assistance with everyday activities in the past 2 years, please explain
In the past 5 years have you:
been confined to a hospital?	Yes No	Yes No
nursing home?	Yes No	Yes No
had home care?	Yes No	Yes No
had long-term care?	Yes No	Yes No
received rehabilitation?	Yes No	Yes No
Please describe your particular health problems
Prescribed medications
Do you currently own a long-term care policy?	Yes No	Yes No
Long-Term Care Quote Selections
Benefit period desired	(Average stay in a nursing facility is about 3 years)
Daily Benefit - nursing home coverage
Daily benefit - home & community care
How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?	The average cost per month is $5,000 which could be more depending on area of country
Inflation protection/cost-of living adjustment	Most needed for younger applicants
Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or Specify other:


	Wealth Guardian Group 3969 E Brae Voe Way \| Queen Creek, AZ 85240 Phone (480) 987-9951 Fax (480) 445-9319

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