Long-Term Care Insurance Application
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Address
Phone Number
Email
Coverage Details
Desired Coverage Amount
Benefit Period (years)
Waiting Period (days)
Inflation Protection
Yes
No
Health Information
Describe your current health status and medical history
Primary Physician Name
Physician Phone
List of Current Medications
Additional Information
Do you have other long-term care coverage?
Yes
No
Additional Notes