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Your Long Term Care Insurance Application

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Personal Profile

APPLICANT A

First Name

Middle Name

Last Name

Street Address

City

State

Zip

Birth Date

State of Birth

Gender

Social Security Number

Phone

Current Primary Occupation

Current Occupational Duties

Citizenship Status

Beneficiary Name

Beneficiary Street Address

Beneficiary City

Beneficiary State

Beneficiary Zip

Beneficiary Relationship To You

Are You Married, Have a Registered Domestic Partner or Have a Partner?

Are They Applying For This Coverage With You?

Does He/She Have An Existing Mutual Of Omaha Insurance Company Long-Term Care Policy/Certificate?

Do You Currently Have Another Long-Term Care Insurance Policy/Certificate In Force (Including Health Care Service Contracts or Health Maintenance Organization Contracts)?

Did You Have Another Long-Term Care Policy/Certificate In Force During The Last 12 Months?

Do You Intend To Replace Other Long-Term Care Coverage Or Any Of Your Medical Or Health Insurance Coverage With This Policy?

Other Insurance Coverage

Company Name/Address

Policy Number

Plan Type

Daily/Monthly Benefit

Status of Policy/Certificate

Annual Premium

To Be Replaced By This Coverage

Sold By This Agent

APPLICANT A

First Name

Middle Name

Last Name

Street Address

City

State

Zip

Birth Date

State of Birth

Gender

Social Security Number

Phone

Current Primary Occupation

Current Occupational Duties

Citizenship Status

Beneficiary Name

Beneficiary Street Address

Beneficiary City

Beneficiary State

Beneficiary Zip

Beneficiary Relationship To You

Are You Married, Have a Registered Domestic Partner or Have a Partner?

Are They Applying For This Coverage With You?

Does He/She Have An Existing Mutual Of Omaha Insurance Company Long-Term Care Policy/Certificate?

Do You Currently Have Another Long-Term Care Insurance Policy/Certificate In Force (Including Health Care Service Contracts or Health Maintenance Organization Contracts)?

Did You Have Another Long-Term Care Policy/Certificate In Force During The Last 12 Months?

Do You Intend To Replace Other Long-Term Care Coverage Or Any Of Your Medical Or Health Insurance Coverage With This Policy?

Other Insurance Coverage

Company Name/Address

Policy Number

Plan Type

Daily/Monthly Benefit

Status of Policy/Certificate

Annual Premium

To Be Replaced By This Coverage

Sold By This Agent

Financial

APPLICANT A

How Will You Pay Each Year's Premium?

Have You Considered Whether You Could Afford To Keep This Policy If The Premiums Went Up, For Example, By 20%?

What Is Your Annual Income?

How Do You Expect Your Income To Change Over The Next 10 Years?

Will You Buy Inflation Protection

How Will You Pay For The Difference Between Future Costs and Your Daily Benefit Amount?

Not Counting Your Home, About How Much Are All Your Assets (Savings and Investments) Worth?

How Do You Expect Your Assets To Change Over The Next 10 Years?

APPLICANT B

How Will You Pay Each Year's Premium?

Have You Considered Whether You Could Afford To Keep This Policy If The Premiums Went Up, For Example, By 20%?

What Is Your Annual Income?

How Do You Expect Your Income To Change Over The Next 10 Years?

Will You Buy Inflation Protection

How Will You Pay For The Difference Between Future Costs and Your Daily Benefit Amount?

Not Counting Your Home, About How Much Are All Your Assets (Savings and Investments) Worth?

How Do You Expect Your Assets To Change Over The Next 10 Years?

Knockout Questions

APPLICANT A

Are You Age 65 Or Older And Has It Been More Than 2 Years Since You Have Had a Doctor's Visit Which Included A Head To Toe Physical Examination With Blood Work (Basic Metabolic Chemistry Panel)?

Do You Currently Use Any Of The Following?

Within The Past 6 Months Have You Been Confined To, Used, Or Advised To Have, Any Of The Following?

Do You Require The Assistance Or Supervision of Another Person Or Device Of Any Kind For Any Of The Following?

Do You Have Diabetes And:

Have You Ever Had, Been Diagnosed As Having, Or Received Medical Advice Or Medical Care From A Physician Or Health Care Provider For Any Of The Following?

Have You Been Diagnosed Or Treated By A Member Of The Medical Profession As Having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?

Do You Currently Qualify For Payment Or Are You Receiving Payment Benefits Under Medicaid/Medi-Cal (Not Medicare) Disability Income Plan, Workers' Compensation, Social Security Disability, Or Any Federal Or State Disability Plan?

APPLICANT B

Are You Age 65 Or Older And Has It Been More Than 2 Years Since You Have Had a Doctor's Visit Which Included A Head To Toe Physical Examination With Blood Work (Basic Metabolic Chemistry Panel)?

Do You Currently Use Any Of The Following?

Within The Past 6 Months Have You Been Confined To, Used, Or Advised To Have, Any Of The Following?

Do You Require The Assistance Or Supervision of Another Person Or Device Of Any Kind For Any Of The Following?

Do You Have Diabetes And:

Have You Ever Had, Been Diagnosed As Having, Or Received Medical Advice Or Medical Care From A Physician Or Health Care Provider For Any Of The Following?

Have You Been Diagnosed Or Treated By A Member Of The Medical Profession As Having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?

Primary Physician Information + Medication

APPLICANT A

Primary Name

Address

City

State

Zip

Phone

Are You Taking Or Have You Taken Any Prescription Medication(s) Within The Past 12 Months, Or Are You Taking Any Over-The-Counter Medication(s) On A Weekly Basis Or More Frequently?

APPLICANT B

Primary Name

Address

City

State

Zip

Phone

Are You Taking Or Have You Taken Any Prescription Medication(s) Within The Past 12 Months, Or Are You Taking Any Over-The-Counter Medication(s) On A Weekly Basis Or More Frequently?

Health Questions

APPLICANT A

Have You Ever Received Any Advice, Treatment, Consultation, Or Diagnosis From A Physician Or Health Care Provider For Any Of The Following Conditions?
(Stability Period Ranging From 3 Months To 5 Years Required To Be Eligible)

In the Past 5 Years, Other Than (Besides) The Primary Care Physician Listed In The Previous Section, Have You Consulted With Any (Other) Medical Professional?

Do You Have, For Your Use, A Handicap Parking Sticker Or Handicap License Plate?

In the Past 3 Years Has A Medical Professional Referred You To A Specialist For Additional Consultation Or Testing?

In The Past 3 Years Has A Medical Professional Referred You To A Specialist For Surgery?

Are You Scheduled For A Visit With A Medical Professional Within The Next 6 Months?

Have You Been Seen By Your Physician, Health Care Provider, Or Any Specialist More Than Three Times In The Past 12 Months?

Have You Received Inpatient Or Outpatient Treatment At A Hospital In The Past 12 Months?

Have You Received Inpatient Or Outpatient Treatment At A Rehabilitation Center In The Past 12 Months?

Have You Received Inpatient Or Outpatient Treatment At A Surgical Center In The Past 12 Months?

Please Enter Your Build Information

Height

ft. in.

Weight (lbs)

Have You Had An Unplanned Weight Change In The Past 12 Months?