Quote Request Form


Your E-mail Address
Name
Age Date of Birth
Spouses Age Date of Birth
Street or PO. Box
City State Zip Code
Phone Number Fax Number
Daily Benefit Needed
 Years of Benefits Elimination Period
Inflation Factor at 5% per year increase
How would you like us to Contact you ?
Spousal Discount...a separate request form will be needed for spouse

PART I
Are you covered by a state assistance program (Medicaid)? YesNo
Due to any present or past mental or physical disability, is any person or institution currently authorized to act on your behalf?
YesNo
Are you dependent on the use of a walker or wheelchair or are you confined to bed or home?
YesNo
Do you use any medical appliance such as a catheter, oxygen equipment, respirator or dialysis machine?
YesNo
Do you require assistance or supervision or are you limited in any way from performing the following daily activities- bathing, dressing, toileting, meal preparation, housekeeping, eating, managing medications, mobility?
YesNo
Have you ever been diagnosed or treated by a member of the medical profession for any of the following:
Acquired Immune Deficiency Syndrome (AIDS)?
 YesNo
Diabetes Mellitus treated with Insulin or Arthritis treated with steroids or gold?
YesNo
Alzheimer's Disease, Organic Brain Syndrome, Senility, Confusion, Disorientation, recurring Memory Loss or Dementia?
YesNo
Parkinson's Disease, Multiple Sclerosis, ALS (Lou Gerhig's Disease) or internal Lupus Erythematosus?
YesNo
Stroke, Congestive Heart Failure, Neurogenic Bladder, Uremia, Chronic Obstructive Pulmonary Disease (COPD), Cirrhosis of the Liver, unoperated Aneurysm or Osteoporosis?
YesNo
PART II
During the past 5 YEARS, have you received medical advice or treatment for the following conditions? (If "yes", V those that apply):
YesNo
Fractures (other than weight bearing joints)
High Blood Pressure
During the past 5 YEARS, have you received medical advice or treatment for any of the following conditions? (If yes check those that apply)
 YesNo
Alcoholism
Amputation
Anemia
Angina
Angioplasty
Arrhythmia
Arteriosclerosis
Arthritis (Prescription Drugs)
Bronchitis (Chronic)
Cancer (internal)
Carotid Artery Disease
Colitis
Coronary By-Pass 		Coronary Insufficiency
Depression
Diabetes Mellitus
Drug or Substance Abuse
Endarterectomy
Fractures (Weight Bearing Joints)
Heart Attack
Joint Replacement
Macular Degeneration
Melanoma
Mental/Nervous Disorders
Spine or Back Disorders
Urinary Incontinence
During the past 12 MONTHS have you?
Been confined to a hospital, nursing home, or sanitarium?
YesNo
Received home care services, physical or rehabilitative therapy?
YesNo
Sought medical advice or treatment for loss of appetite, falling, fainting, unstable gait, bladder control, dizziness, or deterioration of vision?
YesNo
Within the last 5 YEARS, have you been treated by a health professional for any condition not named above?
YesNo

If yes above please list any conditions.
PART III
When you walk 4 blocks at a normal pace do you experience any difficulties such as shortness of breath dizziness or leg cramps?
 YesNo
Have you ever been treated for or diagnosed as having any of the of the following conditions: Heart Disease, Respiratory Disorder (other then Asthma or Acute Brochitis), Amputation, Joint Disorders or Replacement?
YesNo
Do you now or in the past 5 YEARS used any tobacco products, including cigarettes, pipe, cigar, or chewing tobacco?
 YesNo
During the past 10 YEARS have you been confined to a hospital or diagnosed or treated for any of the following conditions? (If yes check those that apply)
 YesNo

Alcoholism
Arthritis (Prescription Drugs)
Cancer (internal)
Diabetes Mellitus
Dizziness
Drug or Substance Abuse
Epilepsy
Melanoma
Mental/Nervous Disorders
Peripheral Vascular Disease
phlebitis

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