Atascadero
4401 El Camino Real Suite A
Atascadero, CA 93422

Phone: (805) 462-0121 or
        (800) 792-5565
Fax: (805) 462-0160

Insurance Prescreening Questionnaire

Please take a moment to fill out this questionnaire, so that we may quickly process your request for health and life insurance services. By filling out this form, we will be able to give you quotes from up to 10 major carriers.

Name:	* Required	Birthday:
Spouse Name:		Spouse Birthday:
Phone Number:	* Required	E-mail Address	* Required
*Note: We will respect your privacy. Your contact information will not be distributed or sold. We only require this information as a means of contacting you regarding your requested coverage.

Coverage Requested:
	(Please Check one)
Nursing Home Care Only (A licensed facility that provides professional services performed in your home. )
Home Health Care Only (Skilled nursing or other professional services performed in your home.)
Comprehensive Care (A combination of nursing home, assisted living, and home care.)
Average daily cost of Nursing Home in your area:
Average daily cost of Skilled Home Health Care in your area:
Average daily cost of Unskilled Home Health Care in your area:
How would you pay for LTC services if you needed them today?
Who would care for you if you became disabled?
How much of your LTC costs are you willing to self-insure?

Health History
	(Check for Yes)		(Check for Yes)
Are you currently using oxygen, a wheelchair, crutches, or a cane?		Spouse:
Are you currently in a nursing home or receiving home health care?		Spouse:
Are you eligible for Medicaid?		Spouse:
Are you currently on disability?		Spouse:
Have you been declined for LTC insurance in the last year?		Spouse:
Have you used tobacco in the last 12 months?		Spouse:
Are you now or have you recently been under a doctor's care for any health conditions?		Spouse:
Do you have surgery scheduled in the next 6 months?		Spouse:
Prescriptions taken on a regular basis:
Spouse's prescriptions taken on a regular basis:
Do you have any physical limitations?		Spouse:
Height/Weight:		Spouse:
	Enter Security Code: