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Proposed Insured's Information
First Name:
Last Name:
Date of birth:
Gender:		Male Female
Last Time Tobacco was used:
Proposed Spouse Information (Skip if No Spouse)
Include Spouse:		INCLUDE SPOUSE NO SPOUSE
Spouse First Name:
Spouse Last Name:
Date of birth:
Gender:		Male Female
Last Time Tobacco was used:
Long Term Care Policy Information
Desired Daily Benefit:
Are Medications being taken:		Primary: No Yes Spouse: No Yes
Been hospitalized in the last 5 years:		Primary: No Yes Spouse: No Yes
If YES to Hospitalization and/or medications, please briefly describe:
Are appliances for mobility used:		Primary: No Yes Spouse: No Yes
If a Long Term Care plan is currently in place, please describe the current benefits and when the plan was purchased:
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