NewmanLTC Online Quote Request

Agent's Name:     Client Meeting Date: (xx/xx/xxxx)     Agent Phone:     Agent Fax:     Agent Email:     Choose method of quote delivery: Email      Fax      US Mail      Will Pick Up Day    Time Check here if client is single (not married/no partner). Check here if client and spouse/partner are applying together. Check here if client is married, but spouse is not applying or is uninsurable. Primary Insured:     Date of Birth:     State of Client Residence:     Last Complete Physical:     Last Tobacco Use:     Height:     Weight:     Secondary Insured:     Date of Birth:     State of Client Residence:     Last Complete Physical:     Last Tobacco Use:     Height:     Weight:     I will pre-screen my clients and provide the underwriting info below to obtain my choice of quotes. I have not pre-screened my client, but would like to receive one quote at standard rates, from just one company to give my clients a ballpark figure. I do not need a quote, but would like you to just pre-screen my client's health history. Primary Insured ANEURYSM, AORTIC - Yes No Is this an ascending or descending aneurysm? Ascending Descending Size of aneurysm (usually in centimeters)? Has it been corrected surgically? Yes No Date: Is surgery planned? Yes No Is there any history of hypertension? Yes No Is there any history of untreated dissecting aortic aneurysm? Yes No Secondary Insured ANEURYSM, AORTIC - Yes No Is this an ascending or descending aneurysm? Ascending Descending Size of aneurysm (usually in centimeters)? Has it been corrected surgically? Yes No Date: Is surgery planned? Yes No Is there any history of hypertension? Yes No Is there any history of untreated dissecting aortic aneurysm? Yes No ANGINA - Yes No What was the age at diagnosis? Within the past 6 months have episodes of angina become more frequent and severe? Yes No Has there been a hospitalization for angina within the past 6 months? Yes No Is there angina at rest? Yes No Are there any ADL or IADL limitations due to angina? Yes No Is there a history of symptomatic Congestive Heart Failure (CHF) or Cardiomyopathy? Yes No Has there been a heart attack (myocardial infarction) or heart surgery? Yes No Is heart surgery recommended or scheduled? Yes No Is the angina musculoskeletal-related? Yes No Any history of Diabetes, Stroke (CVA or TIA), Emphysema or COPD, High Blood Pressure, Kidney Disease, Peripheral Vascular Disease, Neuropathy or Retinopathy? Yes No Explain: ANGINA - Yes No What was the age at diagnosis? Within the past 6 months have episodes of angina become more frequent and severe? Yes No Has there been a hospitalization for angina within the past 6 months? Yes No Is there angina at rest? Yes No Are there any ADL or IADL limitations due to angina? Yes No Is there a history of symptomatic Congestive Heart Failure (CHF) or Cardiomyopathy? Yes No Has there been a heart attack (myocardial infarction) or heart surgery? Yes No Is heart surgery recommended or scheduled? Yes No Is the angina musculoskeletal-related? Yes No Any history of Diabetes, Stroke (CVA or TIA), Emphysema or COPD, High Blood Pressure, Kidney Disease, Peripheral Vascular Disease, Neuropathy or Retinopathy? Yes No Explain: ARTHRITIS - Yes No Type of Arthritis: Please select one Osteoarthritis Rheumatoid Arthritis Degenerative Joint Disease Hypertrophic Arthritis Sjögrens Syndrome Have there been any falls or fractures (including compression fractures)? Yes No Are there any limitations with performing ADLs or IADLs? Yes No Are assistive devices such as wheelchair, walker, quad cane or crutches currently being used? Yes No Is physical therapy currently required? Yes No Has there been any injections in the last 12 months? Yes No Type:    Date: Has major weight bearing joint surgery been completed or suggested? Yes No Joint(s): Date(s) released from treatment: Has there been active rheumatoid arthritis with progressive symptoms within the last 24 months? Yes No ARTHRITIS - Yes No Type of Arthritis: Please select one Osteoarthritis Rheumatoid Arthritis Degenerative Joint Disease Hypertrophic Arthritis Sjögrens Syndrome Have there been any falls or fractures (including compression fractures)? Yes No Are there any limitations with performing ADLs or IADLs? Yes No Are assistive devices such as wheelchair, walker, quad cane or crutches currently being used? Yes No Is physical therapy currently required? Yes No Has there been any injections in the last 12 months? Yes No Type:    Date: Has major weight bearing joint surgery been completed or suggested? Yes No Joint(s): Date(s) released from treatment: Has there been active rheumatoid arthritis with progressive symptoms within the last 24 months? Yes No ATRIAL FIBRILLATION - Yes No When was this diagnosed? When was the episode of atrial fibrillation? If Coumadin is being used, when was the treatment started? And have there been any bleeding episodes? Yes No Has there been a defibrillator implanted in the past 12 months? Yes No Is there any history of congestive heart failure (CHF)? Yes No Is there any history of fainting or falls? Yes No ATRIAL FIBRILLATION - Yes No When was this diagnosed? When was the episode of atrial fibrillation? If Coumadin is being used, when was the treatment started? And have there been any bleeding episodes? Yes No Has there been a defibrillator implanted in the past 12 months? Yes No Is there any history of congestive heart failure (CHF)? Yes No Is there any history of fainting or falls? Yes No CANCER - Yes No What was the location of the cancer? Diagnosis Date: Type of treatment: Final treatment date: Were there any complications associated with treatment? Yes No Has there been more than one type of cancer? Yes No Explain: What was the stage of the cancer? What was the cancer cell type? If Prostrate cancer answer the following questions: What is the current PSA Score? What is the Gleason Score? Was there nodal involvement? Yes No How many: Did the cancer spread to other areas? Yes No CANCER - Yes No What was the location of the cancer? Diagnosis Date: Type of treatment: Final treatment date: Were there any complications associated with treatment? Yes No Has there been more than one type of cancer? Yes No Explain: What was the stage of the cancer? What was the cancer cell type? If Prostrate cancer answer the following questions: What is the current PSA Score? What is the Gleason Score? Was there nodal involvement? Yes No How many: Did the cancer spread to other areas? Yes No CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) / EMPHYSEMA - Yes No Has there been daily or intermittent use of oxygen, IPPB therapy or home respiratory therapy within the last 12 months? Yes No Have there been any hospitalizations for this condition within the past 12 months? Yes No Have there been 2 or more emergency room visits within the past 12 months for respiratory symptoms? Yes No What are the results of Pulmonary Function Tests (PFTs)? Have PFTs been stable for at least 6 months? Yes No Has there been a history of Congestive Heart Failure (CHF) or Cardiomyopathy? Yes No Are activities restricted due to shortness of breath? Yes No CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) / EMPHYSEMA - Yes No Has there been daily or intermittent use of oxygen, IPPB therapy or home respiratory therapy within the last 12 months? Yes No Have there been any hospitalizations for this condition within the past 12 months? Yes No Have there been 2 or more emergency room visits within the past 12 months for respiratory symptoms? Yes No What are the results of Pulmonary Function Tests (PFTs)? Have PFTs been stable for at least 6 months? Yes No Has there been a history of Congestive Heart Failure (CHF) or Cardiomyopathy? Yes No Are activities restricted due to shortness of breath? Yes No CROHN'S DISEASE - Yes No What is the date of onset? Have there been any recent flare ups? Yes No When: Have there been any surgeries, such as a colostomy, performed? Yes No When: Is cancer suspected or testing incomplete? Yes No Has there been a colostomy performed? Yes No When: Has there been any complications, such as: liver disease Yes No malabsorption Yes No megacolon (extremely dilated colon) Yes No bowel perforations Yes No current persistent, severe diarrhea Yes No Has there been any unintentional weight loss of more than 15 pounds in the past 12 months? Yes No CROHN'S DISEASE - Yes No What is the date of onset? Have there been any recent flare ups? Yes No When: Have there been any surgeries, such as a colostomy, performed? Yes No When: Is cancer suspected or testing incomplete? Yes No Has there been a colostomy performed? Yes No When: Has there been any complications, such as: liver disease Yes No malabsorption Yes No megacolon (extremely dilated colon) Yes No bowel perforations Yes No current persistent, severe diarrhea Yes No Has there been any unintentional weight loss of more than 15 pounds in the past 12 months? Yes No DEPRESSION/ANXIETY DISORDERS - Yes No Type: Please select one Anxiety Bipolar Disorder Depression Mania Manic Depression Are there any limitations with performing ADLs or IADLs? Yes No What treatments have been prescribed? History of electro convulsive (shock) therapy (ECT) in the past 48 months? Yes No Lithium in combination with anti-depression medications initiated in the past 24 months? Yes No Anti-psychotic medications initiated in the past 24 months? Yes No Has there been any hospitalizations or emergency rooms visit for depression? Yes No Date: Has there been any hospitalizations or emergency rooms visit for bipolar disorder? Yes No Date: Has there been any history of alcohol or drug dependency? Yes No Last Treatment Date: Has there been an unintentional weight loss of more than 15 pounds in the past 12 months? Yes No Have there been any cognitive symptoms such as memory loss, forgetfulness, confusion, or disorientation within the past 36 months? Yes No Date of Diagnosis: DEPRESSION/ANXIETY DISORDERS - Yes No Type: Please select one Anxiety Bipolar Disorder Depression Mania Manic Depression Are there any limitations with performing ADLs or IADLs? Yes No What treatments have been prescribed? History of electro convulsive (shock) therapy (ECT) in the past 48 months? Yes No Lithium in combination with anti-depression medications initiated in the past 24 months? Yes No Anti-psychotic medications initiated in the past 24 months? Yes No Has there been any hospitalizations or emergency rooms visit for depression? Yes No Date: Has there been any hospitalizations or emergency rooms visit for bipolar disorder? Yes No Date: Has there been any history of alcohol or drug dependency? Yes No Last Treatment Date: Has there been an unintentional weight loss of more than 15 pounds in the past 12 months? Yes No Have there been any cognitive symptoms such as memory loss, forgetfulness, confusion, or disorientation within the past 36 months? Yes No Date of Diagnosis: DIABETES - Yes No Age at diagnosis How is disease being controlled: Please select one Diet/Exercise Oral Medication Insulin Use Insulin Use & Oral Meds If insulin use, how many units per day? What are the latest blood sugar readings? What are the latest A1C ratings? Within the past 12 months has there been a heart attack, bypass surgery, vascular surgery, or laser surgery? Yes No Date: Has there been a Transient Ischemic Attack (TIA), amaurosis fugax, or stroke? Yes No Date(s): Is there any history of Congestive Heart Failure (CHF) or cardiomyopathy? Yes No Has there been a hospitalization within the past 24 months for diabetic complications? Yes No Release Date: Has neuropathy or retinopathy been diagnosed? Yes No Tingling in hands/feet and/or eye problems? Yes No Has there been a history of skin complications (e.g. skin breakdown, foot ulcers, and infections) within the past 24 months? Yes No Has there been a history of recurrent skin complications (e.g. skin breakdown, foot ulcers, and infections)? Yes No Has there has been an amputation or blindness due to diabetes? Yes No DIABETES - Yes No Age at diagnosis How is disease being controlled? Please select one Diet/Exercise Oral Medication Insulin Use Insulin Use & Oral Meds If insulin use, how many units per day? What are the latest blood sugar readings? What are the latest A1C ratings? Within the past 12 months has there been a heart attack, bypass surgery, vascular surgery, or laser surgery? Yes No Date: Has there been a Transient Ischemic Attack (TIA), amaurosis fugax, or stroke? Yes No Date(s): Is there any history of Congestive Heart Failure (CHF) or cardiomyopathy? Yes No Has there been a hospitalization within the past 24 months for diabetic complications? Yes No Release Date: Has neuropathy or retinopathy been diagnosed? Yes No Tingling in hands/feet and/or eye problems? Yes No Has there been a history of skin complications (e.g. skin breakdown, foot ulcers, and infections) within the past 24 months? Yes No Has there been a history of recurrent skin complications (e.g. skin breakdown, foot ulcers, and infections)? Yes No Has there has been an amputation or blindness due to diabetes? Yes No FIBROMYALGIA - Yes No When was it diagnosed? Are there any ADL, IADL limitations? Yes No Are narcotics such as Demerol, Morphine, Percodan or Talwin used to control pain? Yes No Are steroids used? Yes No What medications are being used in the treatment? Yes No How much? Are assistive devices such as a wheelchair, walker, quad cane, or crutches currently being used? Yes No Is there any history of depression or pulmonary compromise? Yes No Has major weight bearing joint surgery been completed within the past 3 months or been recommended? Yes No Have there been any falls or fractures? Yes No How is the condition being treated? Is physical therapy currently required? Yes No FIBROMYALGIA - Yes No When was it diagnosed? Are there any ADL, IADL limitations? Yes No Are narcotics such as Demerol, Morphine, Percodan or Talwin used to control pain? Yes No Are steroids used? Yes No What medications are being used in the treatment? Yes No How much? Are assistive devices such as a wheelchair, walker, quad cane, or crutches currently being used? Yes No Is there any history of depression or pulmonary compromise? Yes No Has major weight bearing joint surgery been completed within the past 3 months or been recommended? Yes No Have there been any falls or fractures? Yes No How is the condition being treated? Is physical therapy currently required? Yes No HEART DISEASE - Yes No Any heart surgeries or procedures (please provide dates of procedures): Bypass (# of vessels involved) - Date: Heart valve replacement - Date: Angioplasty (# of stents) - Date: Aneurysm Surgery - Date: Pacemaker - Date: Other - Date: Defibrillator - Date: Has client fully recovered from any procedure that was done? Yes No Is client released from doctor's care? Yes No Does client have restrictions on activity? Yes No Any heart attack, Cardiomyopathy, congestive heart failure, artrial fibrillation or chest pains? Yes No Please provide dates of procedures: Does client have regular follow up with doctor? Yes No Are stress tests or echocardiograms done and negative? Yes No For aneurysm if not operated, what size is it and has it grown in the last 2 years? Has client experienced any cardiac symptoms such as chest pain, shortness of breath, activity intolerance, dizziness or fainting within the last few years? Yes No Please explain and provide dates: Has client had any abnormal EKGs? Yes No Provide details. Has heart been in normal sinus rhythm for over 2 years? What is the ejection fraction of the heart? Any pending tests or procedures? Yes No HEART DISEASE - Yes No Any heart surgeries or procedures (please provide dates of procedures): Bypass (# of vessels involved ) - Date: Heart valve replacement - Date: Angioplasty (# of stents ) - Date: Aneurysm Surgery - Date: Pacemaker - Date: Other - Date: Defibrillator - Date: Has client fully recovered from any procedure that was done? Yes No Is client released from doctor's care? Yes No Does client have restrictions on activity? Yes No Any heart attack, Cardiomyopathy, congestive heart failure, artrial fibrillation or chest pains? Yes No Please provide dates of procedures: Does client have regular follow up with doctor? Yes No Are stress tests or echocardiograms done and negative? Yes No For aneurysm if not operated, what size is it and has it grown in the last 2 years? Has client experienced any cardiac symptoms such as chest pain, shortness of breath, activity intolerance, dizziness or fainting within the last few years? Yes No Please explain and provide dates: Has client had any abnormal EKGs? Yes No Provide details. Has heart been in normal sinus rhythm for over 2 years? What is the ejection fraction of the heart? Any pending tests or procedures? Yes No HYPERTENSION/HIGH BLOOD PRESSURE - Yes No What are the most recent blood pressure readings? Have blood pressure readings been stable? Yes No How long have blood pressure readings been stable? How many HBP meds are being taken (very important)? Has there been a hospitalization or ER visit for hypertension or congestive heart failure? Yes No Is there current or recent tobacco use? Yes No Is there a history of diabetes? Yes No Is there a history of atrial fibrillation? Yes No Is there a history of coronary artery disease? Yes No Is there a history of Transient Ischemic Attack (TIA) or stroke? Yes No Is there a history of kidney problems? Yes No HYPERTENSION/HIGH BLOOD PRESSURE - Yes No What are the most recent blood pressure readings? Have blood pressure readings been stable? Yes No How long have blood pressure readings been stable? How many HBP meds are being taken (very important)? Has there been a hospitalization or ER visit for hypertension or congestive heart failure? Yes No Is there current or recent tobacco use? Yes No Is there a history of diabetes? Yes No Is there a history of atrial fibrillation? Yes No Is there a history of coronary artery disease? Yes No Is there a history of Transient Ischemic Attack (TIA) or stroke? Yes No Is there a history of kidney problems? Yes No OSTEOPOROSIS - Yes No Have there been any falls or fractures (including compression fractures)? Yes No hip fracture? - Date: vertebral fracture? - Date: pelvic fracture? - Date: three or more fractures - Date: other? - Date: What are bone density scores (T-scores)? Hip Femur Other Are there any limitations with performing ADLs or IADLs? Yes No Are assistive devices such as wheelchair, walker, quad cane or crutches currently being used? Yes No Is physical therapy currently required? Yes No Is pulmonary function impaired? Yes No OSTEOPOROSIS - Yes No Have there been any falls or fractures (including compression fractures)? Yes No hip fracture? - Date: vertebral fracture? - Date: pelvic fracture? - Date: three or more fractures - Date: other? - Date: What are bone density scores (T-scores)? Hip Femur Other Are there any limitations with performing ADLs or IADLs? Yes No Are assistive devices such as wheelchair, walker, quad cane or crutches currently being used? Yes No Is physical therapy currently required? Yes No Is pulmonary function impaired? Yes No SLEEP APNEA - Yes No Smoker? Yes No Smoked in the past 12 months? Yes No Corrected surgically? Yes No Date: Is surgery planned? Yes No Is a CPAP (Continuous Positive Airway Pressure) being used? Yes No Did the use of a CPAP begin within the past 3 months? Yes No (If yes, not insurable.) Has the use of CPAP apparatus been recommended but not used? Yes No (If yes, not insurable.) Is Supplemental oxygen required? Yes No (If yes, not insurable.) Cardiac disease? Yes No (If yes, possible decline.) Hypertension? Yes No (If yes, possible rating.) Are there any functional limitations? Yes No If yes, what? Are there any significant cardiac or respiratory conditions? Yes No If yes, what? Does it affect daytime functions? Yes No SLEEP APNEA - Yes No Smoker? Yes No Smoked in the past 12 months? Yes No Corrected surgically? Yes No Date: Is surgery planned? Yes No Is a CPAP (Continuous Positive Airway Pressure) being used? Yes No Did the use of a CPAP begin within the past 3 months? Yes No (If yes, not insurable.) Has the use of CPAP apparatus been recommended but not used? Yes No (If yes, not insurable.) Is Supplemental oxygen required? Yes No (If yes, not insurable.) Cardiac disease? Yes No (If yes, possible decline.) Hypertension? Yes No (If yes, possible rating.) Are there any functional limitations? Yes No If yes, what? Are there any significant cardiac or respiratory conditions? Yes No If yes, what? Does it affect daytime functions? Yes No STROKE - Yes No Have there been multiple episodes of stroke? Yes No Are there any residual effects? Yes No Are there any limitations of ADLs? Yes No Are there any co-morbid factors? atrial fibrillation (type of irregular heartbeat) damaged heart valve carotid heart disease high cholesterol diabetes If single episode, date of episode: STROKE - Yes No Have there been multiple episodes of stroke? Yes No Are there any residual effects? Yes No Are there any limitations of ADLs? Yes No Are there any co-morbid factors? atrial fibrillation (type of irregular heartbeat) damaged heart valve carotid heart disease high cholesterol diabetes If single episode, date of episode: SURGERIES/HOSPITAL STAYS - Yes No Date Reason Treatment & result Date Reason Treatment & result Date Reason Treatment & result Are there any pending surgeries? Yes No SURGERIES/HOSPITAL STAYS - Yes No Date Reason Treatment & result Date Reason Treatment & result Date Reason Treatment & result Are there any pending surgeries? Yes No TRANSIENT ISCHEMIC ATTACK (TIA) - Yes No Has there been more than one TIA? Yes No If yes, how many? Has there been a TIA in the past 6 months? Yes No Date of episode(s): Are there any residual effects? Yes No Are there any co-morbid factors: atrial fibrillation (type of irregular heartbeat)? damaged heart valve? carotid heart disease? high cholesterol? diabetes? Have there been multiple episodes of Amaurosis Fugax (temporary loss of vision)? Yes No Is there a history of any heart surgery (e.g., angioplasty, bypass grafts, valve replacements)? Yes No Have there been recent symptoms of a TIA (e.g., temporary numbness, tingling, loss of vision or garbled speech)? Yes No TRANSIENT ISCHEMIC ATTACK (TIA) - Yes No Has there been more than one TIA? Yes No If yes, how many? Has there been a TIA in the past 6 months? Yes No Date of episode(s): Are there any residual effects? Yes No Are there any co-morbid factors: atrial fibrillation (type of irregular heartbeat)? damaged heart valve? carotid heart disease? high cholesterol? diabetes? Have there been multiple episodes of Amaurosis Fugax (temporary loss of vision)? Yes No Is there a history of any heart surgery (e.g., angioplasty, bypass grafts, valve replacements)? Yes No Have there been recent symptoms of a TIA (e.g., temporary numbness, tingling, loss of vision or garbled speech)? Yes No Other Health Conditions Not Listed Above - Yes No Other Health Conditions Not Listed Above - Yes No Prescription Medications Being Used - Yes No Med Condition Taken For Dose How Often Prescription Medications Being Used - Yes No Med Condition Taken For Dose How Often BENEFIT SELECTION: Monthly Benefit: Elimination Period: Choose one 0 day 30 day 60 day 90-100 day 180 day 365 day Benefit Period: Choose one 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 10 Years Inflation Protection: Choose one Compound Simple GPO/None Other Additional Riders: Waiver of Home Care EP SharedCare Survivorship Restoration of Benefits Calendar Day Elimination Period (not available with waiver of EP) Return of Premium Cash Benefit (not available on all policies) Other: Company Preferences? Competition? Yes No If yes, who? Additional Agent Notes: