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Evidence of Insurability

Evidence of Insurability. Pre-Qualification Request for Quote. Pre-Qualification. Agent Name: State: Client Name: Date of Birth:­ Height: Weight : Any use of tobacco products in the last 5 years? Y N Do you have a medical history of, or currently have, any of the following conditions?

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Evidence of Insurability

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  1. Evidence of Insurability Pre-Qualification Request for Quote

  2. Pre-Qualification Agent Name:State: Client Name: Date of Birth:­ Height:Weight: Any use of tobacco products in the last 5 years? Y N Do you have a medical history of, or currently have, any of the following conditions? Abdominal, cerebral or thoracic aneurysm Y N Cancer of Internal organs Y N Chronic Respiratory Disease (Asthma, COPD, Sleep Apnea) Y N Circulatory Disease (Carotid Artery, Coronary Artery, Vascular) Y N Depression or Anxiety Y N Diabetes Y N Fibromyalgia, Chronic Fatigue Syndrome Y N Heart Disease Y N Joint Replacement Y N Macular Degeneration, Blindness Y N Continued on next page

  3. Pre-Qualification Continued Osteoporosis Y N Restless Leg Syndrome, Tremors Y N Arthritis, Rheumatoid Arthritis Y N Seizure Disorder Y N Transient Ischemic Attack (TIA), Retinal Occulsion, Stroke Y N Ulcerative Colitis, Crohn’s Disease, Gastric Bypass Y N Detail of Chronic Conditions: Condition Name Diagnosis Date Continued on next page

  4. Pre-Qualification Continued Medications:Diagnosis Date: Are your average blood pressure readings greater than 135/85? Y N Are you currently receiving, or have you received any disability Y N benefits with the past 12 months? Within the past 12 months, have any surgeries or diagnostic tests Y N been recommended but not performed? Have you been declined, postponed, or rated for LTC Insurance? Y N If yes above, reason? Please return to: Mary Sizemore, CLTC LTC Solutions 657-333-LTCS (5827) Fax #239-540-0098 mary@LTCSolutions.net

  5. Request for Quote Information Needed for a Quote: • Agent’s Name, Telephone # & Email Address • Client’s Name, DOB, Marital Status & State of Residence • Carrier of Interest • Daily or Monthly Benefit • Benefit Period (Multiplier) • Elimination Period • Inflation Protection • Additional Riders

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