FL
Bar Member #:
Phone Number:
FaxNumber:
E-mail Address:
Mailing
Address:
City:
State:
Zip:
How did you hear
about us?:
Please Choose
Print Ad
Web Banner
FL Bar Website
Direct Mail
Referral
The Florida Bar
Email
Search Engine
Person
#1
Name:
Date of
Birth:
Gender:
Male
Female
Please choose...
Tobacco:
Never
Smoker
Smokeless Chew
Quit less than 5 yrs
ago
Quit more than 5 yrs
ago
Relation
to Bar Member:
Please choose...
Member
Spouse
Parent
Height/Weight:
4
5
6
7
ft.
0
1
2
3
4
5
6
7
8
9
10
11
inches
lbs.
Have you been hospitalized in the past
5 years? If so, for what duration and condition?
Are you currently taking any prescription
medications? If yes,
Name, Dosage, How long and for what condition(s).
Do you have any pending surgery? If
yes, provide details.
Do you currently have or have you ever had in the past any
serious medical problems such as: Diabetes, Cancer, Heart
Problems, Stroke, or Osteoporosis? If so, need to know details
such as when, treatment, and current status.
Any physical limitations? Support devices? Type?
Reason for use? Duration?
Do you have any medical conditions or problems
not already metioned above?
Financial
Questions
As important as long term care insurance is, it is not for everyone.
These next two questions will help us determine if financially,
purchasing long term care insurance makes sense for your situation
or is there a better way for you to address this issue. We have
intentionally made these questions very broad, however if you
are uncomfortable answering them just leave them blank and we
can discuss them when we speak.
With the cost of
care averaging in excess of $70,000 per year, if you had to
use your own assets to pay for your care, (do not include the
value of your home) approximately how long could you afford
to pay for your own care?
Please choose...
Less than 1 year
1 year
2 years
3 years
More than 3 years
After paying all
of your bills each month, approximately how much "left
over" or descrectionary income do you have?
Please choose...
Less than $200
$200 - $500
$500 - $1000
More than $1000
Person
#2
Name:
Date of
Birth:
Gender:
Male
Female
Please choose...
Tobacco:
Never
Smoker
Smokeless Chew
Quit less than 5 yrs
ago
Quit more than 5 yrs
ago
Relation
to Bar Member:
Please choose...
Member
Spouse
Parent
Height/Weight:
4
5
6
7
ft.
0
1
2
3
4
5
6
7
8
9
10
11
inches -
lbs.
Have you been hospitalized in the past
5 years? If so, for what duration and condition?
Are you currently taking any prescription
medications? If yes,
Name, Dosage, How long and for what condition(s).
Do you have any pending surgery? If
yes, provide details.
Do you currently have or have you ever had in the past any
serious medical problems such as: Diabetes, Cancer, Heart
Problems, Stroke, or Osteoporosis? If so, need to know details
such as when, treatment, and current status.
Any physical limitations? Support devices? Type?
Reason for use? Duration?
Do you have any medical conditions or problems
not already metioned above?
Financial
Questions
As important as long term care insurance is, it is not for everyone.
These next two questions will help us determine if financially,
purchasing long term care insurance makes sense for your situation
or is there a better way for you to address this issue. We have
intentionally made these questions very broad, however if you
are uncomfortable answering them just leave them blank and we
can discuss them when we speak.
With the cost of
care averaging in excess of $70,000 per year, if you had to
use your own assets to pay for your care, (do not include the
value of your home) approximately how long could you afford
to pay for your own care?
Please choose...
Less than 1 year
1 year
2 years
3 years
More than 3 years
After paying all
of your bills each month, approximately how much "left
over" or descrectionary income do you have?
Please choose...
Less than $200
$200 - $500
$500 - $1000
More than $1000
Important Disclaimer: This is NOT an application for insurance.
This is simply an information gathering tool by which we can
generate accurate premium quotations and make recommendations
for long term care insurance. No insurance will go into effect
until after you complete an actual application to an insurer,
pay your first premium, and are approved by the insurer.