RIA LTC Form

Long Term Care Questionnaire

Please complete this form to aid in the preparation of your insurance quote. Completion of this form does not constitute completion and/or submission of an application for insurance.

If you have questions, please email insurance@dbs-lifemark.com or call:

Jim Boldischar: 877.593.7655

Please note the use of some medications or narcotics for pain; etc. may result in a decline or postpone as well as current or ongoing treatment for Physical Therapy and joint injections (may be a waiting period to reapply) or Chiropractor.

All completed forms are submitted via our secure server so you can be assured that your information is safe with us.

Name of Advisor you are working with:
First Last
Applicant's Name*
First Last
Email
Social Security Number
Driver's License
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
State of Issue/Delivery*
State
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Place of birth*
Height*
ft. in.
Weight*
lbs.
Income
Net Worth
Occupation (if retired, add retired)*
Employer (if retired, add retired)*
Primary Phone*
Beneficiary Information
First Name Last Name Relationship
Marital Status*
- Married
- Divorced
- Widowed
- Separated
- Never married
Current cigarette smoker?*
- No
- Yes
Ever a cigarette smoker?*
- No
- Yes
Date of last cigarette use:*
MM slash DD slash YYYY
Any other tobacco use?*
- No
- Yes
Cigar, pipe, snuff/chew, patch, gum, e-cigarette, vape
Details regarding other tobacco use:*
Date of last use (other form)*
MM slash DD slash YYYY
Do you have an LTC policy or have you been declined or lapsed an LTC policy in the last 12 months?*
- Yes
- No
Primary Doctor Name*
First Last
Primary Doctor Phone*
Primary Doctor Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
In the last 5 years, have you received medical advice, diagnosis or treatment, or consulted with a member of the medical profession for any of the following conditions?
Circulatory Disorders: Aneurysm, Cardiomyopathy, Carotid Artery Disease, Congestive Heart Failure, Coronary Artery Disease, Embolisms, Heart Arrhythmias, High Blood Pressure, Peripheral Vascular Disease, Stroke, Transient Ischemic Attack, Vascular Disease?*
- No
- Yes
Please provide details in the space below.*
Cancer or a tumor, cyst, or growth?*
- No
- Yes
Type of cancer:*
Stage and/or grade:*
Please provide additional details.*
Endocrine and Pituitary Disorders: Diabetes, Pancreatitis?*
- No
- Yes
Please provide details in the space below.*
Any Bladder Disorders, Incontinence, Kidney Failure, Prostate Disorders, Renal Insufficiency?*
- No
- Yes
Please provide details in the space below.*
Gastrointestinal Disorders: Cirrhosis, Crohn’s Disease, Hepatitis, Liver Disorders, Ulcerative Colitis?*
- No
- Yes
Please provide details in the space below.*
Anxiety, Chronic Fatigue Syndrome, Depression, Mental Illness, Neuropathy, Seizures, Tremors?*
- No
- Yes
Please provide details in the space below.*
Blood Disorders: Anemia, Hemochromatosis, Polycythemia Vera, Thrombocytopenia?*
- No
- Yes
Please provide details in the space below.*
Musculoskeletal Disorders: Arthritis, Degenerative Joint Disease, Fibromyalgia, Fractures, Lupus, Osteoarthritis, Osteopenia, Osteoporosis, Paralysis, Polymyalgia Rheumatic, Rheumatoid Arthritis , Scoliosis, Spinal Stenosis?*
- No
- Yes
Please provide details in the space below.*
Asbestosis, Asthma, Bronchiectasis, Bronchitis, Chronic Obstructive Pulmonary Disease, Emphysema, Sarcoidosis, Sleep Apnea?*
- No
- Yes
Please provide details in the space below.*
Eye & Ear Disorders: Glaucoma, Macular Degeneration, Meniere’s/Vertigo, Retinitis Pigments?nervous system?*
- No
- Yes
Please provide details in the space below.*
Substance Abuse: Alcoholism, Drug dependency, Illicit drug use?*
- No
- Yes
Please provide details in the space below.*
Has the applicant had a complete exam within the past 18 months?*
- No
- Yes
Please indicate the date and any significant findings.*
Have you had any surgeries in the last 6 months or are there plans for surgery in the near future?*
- No
- Yes
Please provide details in the space below.*
Are you currently or have you taken any medications within the last two years?*
- No
- Yes
Please list medications currently taking, including dosage and frequency.*
Does the applicant (check ALL that apply)*
- Currently use any assistive or mechanical devices?
- Currently receive (or ever received) home health care, been confined to a nursing home, or rehabilitation center?
- Require human assistance or supervision in performing any of your activities of daily living?
- Currently receive disability benefits?
- Currently see any specialists?
- Receive any joint injections: Cortisone or other steroid medication in the last 6 months?
- None of the above
Please provide details to any "yes" answers in the space below.*
Does the applicant (check ALL that apply)*
- Take any narcotics for pain?
- Participate in any ongoing Physical Therapy or treatments in the last 6 months?
- Have any Chiropractor visits?
- None of the above
Please provide details to any "yes" answers in the space below.*
Please provide any additional details that may be helpful.

Long Term Care Questionnaire

In the last 5 years, have you received medical advice, diagnosis or treatment, or consulted with a member of the medical profession for any of the following conditions?