USI Midwest: Individual Long Term Care Insurance

Individual Long Term Care Insurance Request Form

This electronic form is ADA compliant! Please complete all fields. If a field is not required enter 'N/A'.

COVERAGE INFORMATION

DAILY BENEFIT AMOUNT
DAILY BENEFIT PERIOD

CHECK APPLICABLE RIDERS
Home Health Care Rider	Indemnity Benefit Rider
Nonforfeiture Rider	Caregiver Indemnity Rider
Inflation Rider

APPLICANT INFORMATION

APPLICANT NAME
APPLICANT DOB	(##/##/####)
APPLICANT HEIGHT
APPLICANT WEIGHT
APPLICANT GENDER	Male Female
APPLICANT TOBACCO USER	No Yes

SPOUSE INFORMATION

SPOUSE NAME
SPOUSE DOB	(##/##/####)
SPOUSE HEIGHT
SPOUSE WEIGHT
SPOUSE GENDER	Male Female
SPOUSE TOBACCO USER	No Yes
ADD SPOUSE TO QUOTE?	No Yes

MEDICAL HISTORY

Have you or any family members to be insured had any major illnesses or injuries in the last five years? If yes, provide name, diagnosis/type of injury, dates, outcome, residual effects:

Do you or any family members to be insured take prescription medication(s)? If yes, provide name, medication, dosage, frequency and start date:

LOCATION AND CONTACT INFORMATION

APPLICANT EMAIL:
APPLICANT PHONE
APPLICANT FAX:
APPLICANT STREET
APPLICANT COUNTY
APPLICANT CITY
APPLICANT STATE
APPLICANT ZIPCODE

OTHER INFORMATION

Effective Date of Coverage:
Premium Level Mode:
CCOC Agent Name (if member)
AMA Agent Name (if member)
WSE Agent Name (if member)

Current Carrier Plan and Date
No coverage as of now.

Any other comments or concerns that you feel we should know about?



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