Request a Quote

It is my goal to simplify your long-term care insurance shopping experience.

It’s impossible to get “instant” quotes for long term care insurance. Long-term care insurance premiums are based upon your health history and the specific benefits that you want in your policy. That is why I’ve provided a detailed Health History questionnaire below. After you complete the questionnaire, I’ll be able to provide you with quotes from several of the leading long-term care insurance policies‐and I’ll be able to help you tailor the policy to meet your specific needs and goals.

When comparing nearly identical policies, premiums will usually vary by as much as 35% to 55%. That’s why it’s important to shop for long-term care insurance. I will only include quotes from those insurers which meet high standards for financial stability. Please complete the questions below, and I will be in touch shortly. Feel free to call 540-752-2657 or email me if you have any questions.

Your Contact Information
Name*
First Last
Date of Birth:*
MM slash DD slash YYYY
Address:*
Street Address Address Line 2 City State ZIP Code
How did you get to this questionnaire?*
- Someone referred me to Ray's site.
- Ray sent me a link.
- I found the site online
- Other
Please tell me who so I can thank them:
Please tell us how:*
E-mail:*
Preferred Phone:*
Best time to call?*

: Hours

Minutes

AM/PM
Secondary Phone:
Height?*
Weight?*
Weight 12 months ago?*
Have you used any type of tobacco in the last five (5) years?*
- Yes
- No
If yes, when did you last use tobacco?
Your Medication List
Current medications that you are taking:
Name of Medication: Dosage: Purpose:

Click the + to add additional medications
Your Medical History
Surgery or hospital stay or emergency room visit?*
- Yes
- No
Cancer, including skin cancer*
- Yes
- No
Stroke, mini-stroke, or Bell’s Palsy*
- Yes
- No
Arthritis or any joint replacement*
- Yes
- No
Heart surgery, heart disorders, peripheral vascular disease, or aneurysm, embolism or other circulatory disorders*
- Yes
- No
Physical therapy, speech therapy or other rehabilitative care*
- Yes
- No
Multiple Sclerosis, Lou Gehrig’s disease (ALS), Parkinson’s disease or any other disorder of the nervous system*
- Yes
- No
Bone fracture, Osteoporosis or Osteopenia*
- Yes
- No
Back, spine, or neck disorders or surgery*
- Yes
- No
Auto-immune disorders like Lupus, Fibromyalgia, Polymyalgia Rheumatica, or CREST syndrome*
- Yes
- No
Persistent memory loss, Alzheimer’s disease or any type of dementia*
- Yes
- No
Pre-diabetes, Diabetes or any diabetic complications like neuropathy*
- Yes
- No
Sleep disorders, sleep apnea, CPAP use, or Restless Leg Syndrome*
- Yes
- No
Asthma, Bronchitis, Chronic Obstructive Pulmonary Disease, or other lung disorders*
- Yes
- No
High blood pressure*
- Yes
- No
Stress incontinence, or bowel or bladder incontinence, use of a catheter or colostomy*
- Yes
- No
Epilepsy or any type of seizures*
- Yes
- No
Neuralgia, Neuropathy, Polyneuropathy, Chronic Fatigue Syndrome or any type of chronic pain*
- Yes
- No
Use of a cane, walker, wheelchair or scooter*
- Yes
- No
Pancreatitis, kidney or liver disorders, any type of Hepatitis, or any type of blood disorders*
- Yes
- No
Anxiety, depression, bipolar, or any other type of mental/nervous disorder*
- Yes
- No
Are you currently receiving any type of disability benefits?*
- Yes
- No
Has it been recommended that you have some type of surgery or therapy in the next 24 months (including elective procedures)?*
- Yes
- No
For any questions marked ‘yes’ in the fields above, please provide as many details as possible
Do you have a spouse or live-in partner who would also like coverage?*
- Yes
- No
Spouse/Partner Information
Name
First Last
Date of Birth:
MM slash DD slash YYYY
Address:
Same as previous

Street Address Address Line 2 City State ZIP Code
Height?
Weight?
Weight 12 months ago?
Have your spouse or partner used any type of tobacco in the last five (5) years?
- Yes
- No
If yes, when did they last use tobacco?
Spouse/Partner Medication List
Current medications your spouse/partner is taking:
Name of Medication: Dosage: Purpose:

Click the + to add additional medications
Spouse/Partner Medical History
Surgery or hospital stay or emergency room visit?
- Yes
- No
Cancer, including skin cancer
- Yes
- No
Stroke, mini-stroke, or Bell’s Palsy
- Yes
- No
Arthritis or any joint replacement
- Yes
- No
Heart surgery, heart disorders, peripheral vascular disease, or aneurysm, embolism or other circulatory disorders
- Yes
- No
Physical therapy, speech therapy or other rehabilitative care
- Yes
- No
Multiple Sclerosis, Lou Gehrig’s disease (ALS), Parkinson’s disease or any other disorder of the nervous system
- Yes
- No
Bone fracture, Osteoporosis or Osteopenia
- Yes
- No
Back, spine, or neck disorders or surgery
- Yes
- No
Auto-immune disorders like Lupus, Fibromyalgia, Polymyalgia Rheumatica, or CREST syndrome
- Yes
- No
Persistent memory loss, Alzheimer’s disease or any type of dementia
- Yes
- No
Pre-diabetes, Diabetes or any diabetic complications like neuropathy
- Yes
- No
Sleep disorders, sleep apnea, CPAP use, or Restless Leg Syndrome
- Yes
- No
Asthma, Bronchitis, Chronic Obstructive Pulmonary Disease, or other lung disorders
- Yes
- No
High blood pressure
- Yes
- No
Stress incontinence, or bowel or bladder incontinence, use of a catheter or colostomy
- Yes
- No
Epilepsy or any type of seizures
- Yes
- No
Neuralgia, Neuropathy, Polyneuropathy, Chronic Fatigue Syndrome or any type of chronic pain
- Yes
- No
Use of a cane, walker, wheelchair or scooter
- Yes
- No
Pancreatitis, kidney or liver disorders, any type of Hepatitis, or any type of blood disorders
- Yes
- No
Anxiety, depression, bipolar, or any other type of mental/nervous disorder
- Yes
- No
Is your spouse/partner currently receiving any type of disability benefits?
- Yes
- No
Has it been recommended that your spouse/partner have some type of surgery or therapy in the next 24 months (including elective procedures)?
- Yes
- No
For any questions marked ‘yes’ in the fields above, please provide as many details as possible

Name of Medication:	Dosage:	Purpose:

Name of Medication:	Dosage:	Purpose:

Request a Quote

Your Contact Information

Your Medication List

Your Medical History

Spouse/Partner Information

Spouse/Partner Medication List

Spouse/Partner Medical History