120 Broadway Amityville, NY 11701
631-841-0270
eeaton@eatoninsurance.com
Fax- (631) 841-0509
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Long Term Care
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Insurance Form
Long Term Care
Application Form
Please complete this form and we will contact you with a quote
Personal Information:
Last Name *
First Name *
Email Address *
Street Address*
City *
State *
Zip *
Phone *
Birth Date *
Gender
Male
Female
Height
Weight
Are you married?
Yes
No
If yes, Spouse's Birth Date
Height(spouse):
Weight(spouse):
Fill in Spouse if Spouse is also applying
Do you smoke?
Yes
No
Spouse smoke?
Yes
No
Are you diabetic?
Yes
No
Spouse diabetic?
Yes
No
Are you insulin dependent?
Yes
No
Spouse insulin dependent?
Yes
No
Do you use a cane?
Yes
No
Spouse use a cane?
Yes
No
Do you use a walker?
Yes
No
Spouse use a walker?
Yes
No
Do you use a wheelchair?
Yes
No
Spouse use a wheelchair?
Yes
No
Do you use any other equipment?
Yes
No
Spouse use any other equipment?
Yes
No
Please explain if you have required assistance with everyday activities in the past 2 years?
Please explain if your spouse has required assistance with everyday activities in the past 2 years?
In the past 5 years have you: (Check all that apply)
been confined to a hospital?
nursing home?
had home care?
had long-term care?
received rehabilitation?
Please describe your particular health problems:
In the past 5 years has your spouse: (Check all that apply)
been confined to a hospital?
nursing home?
had home care?
had long-term care?
received rehabilitation?
Please describe your spouse's particular health problems:
Prescribed Medications:
Spouse's Prescribed Medications:
Do you currently own a long-term care policy?
Yes
No
Does your spouse currently own a long-term care policy?
Yes
No
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