Optional Fields for information only purposes

Do you currently own a long-term care policy that you would like to compare with other plans available: Yes: No:
If yes, List Carrier and Year purchased:

In the past 5 years, have you or your spouse used tobacco products, including cigarettes, pipe, cigar, or chewing tobacco?

You:

: Yes

No

Your Spouse:

Yes

No

During the past 10 years have you been confined to a hospital, nursing home, received home care or diagnosed or treated for any serious condition? If so, please describe.

You:

Yes

No

Your Spouse:

Yes

No

Please list all medications you are currently taking and what they are for:

You:	Your Spouse:

Comments of Questions

Please list any additional comments or questions you have: