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Long-Term Care Insurance
Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible.  Once submitted the information will be e-mailed to our office(s) and we will expedite your request.  This information will be kept confidential and will be used for quote purposes only.  We look forward to serving you.
 

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information

* Name:
Address:
City:
State: Zip:
Phone: * Work:
* Home: 
*  Cell:
 Fax: 
* Email Address:
*Best date and time to be reached in the next 48 hours.
Date:
/
 
MM
/
DD
Time:

Quote Information

Date of Birth: / /
Gender: Male   Female
Tobacco User?: Yes   No
Height & Weight: (ex: 5' 8")
 (ex: 150 lbs)
Do you require assistance or supervision to perform every day activities such as walking, cooking, eating, bathing, toileting or dressing? No   Yes
Do you require the use of oxygen or a wheelchair, walker or cane? No   Yes
Have you ever been diagnosed or treated for the following:
Alzheimer’s disease Yes   No
Parkinson’s disease Yes   No
Psychosis Yes   No
Multiple Sclerosis Yes   No
Muscular Dystrophy Yes   No
Myasthenia Gravis Yes   No
Chronic Liver Disease Yes   No
Hodgkin’s disease Yes   No
Chronic Brain Syndrome Yes   No
Systemic Lupus Yes   No
Immune Deficiency (e.g. AIDS or AIDS- related complex) Yes   No
Have you required surgery within the past six months (except for cataract or superficial skin surgery? Yes   No
Do you have any recommended surgery, diagnostic testing, special work-up, or hospitalization that has not yet been performed? Yes   No
Do you have emphysema, asthma, chronic bronchitis or chronic obstructive pulmonary isease combined with any use of tobacco within the last year? Yes   No
Are you currently taking any prescription medications? List any medication and dosage you are currently taking Yes   No
Please List those medications.  
Have you ever mentioned memory loss to your doctor? Yes   No
Do you now have, or do you have any history of the following:
Heart trouble? Yes   No
Cancer or Leukemia? Yes   No
Arthritis (rheumatoid or osteo) requiring prescription medication? Yes   No
Osteoporosis, spinal problems, chronic back disorder or vertebrae fractures? Yes   No
Emphysema, chronic bronchitis, chronic obstructive pulmonary disease (COPD)? Yes   No
Stroke, TIA (transient ischemic attack) or carotid artery disease? Yes   No
Joint replacement? Yes   No
Drug abuse or alcohol treatment within the last five years? Yes   No
Macular degeneration or glaucoma? Yes   No
Mental disorder requiring hospitalization? Yes   No
Tremors, epilepsy, seizure disorder or lupus? Yes   No
Depression? Yes   No
Type I Diabetes? Yes   No
Type II Diabetes? Yes   No
Use of Insulin? Yes   No

Spouse/Companion Information

For coverage for spouse/companion please complete additional quote request.

Family History

 
Age
Health (If Living)
If deceased, cause of death
Age
Mother
Father
Brothers
Sisters

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.

Please click on the "Submit Request" button to send us your quote request.

    



     

Dominion Financial Group, Inc.
5520 Wellesley St., Suite 203
La Mesa, CA 91942
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(619) 644-3545 – Office
(619) 644-3550 – Fax

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