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Request For Quote Form
Please fill out the form below completely.

Your E-mail Address

Name

Age	Date of Birth

Spouses Age	Date of Birth

Street or PO. Box

City	State	Zip Code

Phone Number	Fax Number

Daily Benefit Needed	Years of Benefits	Elimination Period	Inflation Factor at 5% per year increase
How would you like us to Contact you ?
Spousal Discount...a separate request form will be needed for spouse Height Weight

PART ONE

Are you covered by a state assistance program (Medicaid)?

Due to any present or past mental or physical disability, is any person or institution currently authorized to act on your behalf?

Are you dependent on the use of a walker or wheelchair or are you confined to bed or home?

Do you use any medical appliance such as a catheter, oxygen equipment, respirator or dialysis machine?

Do you require assistance or supervision or are you limited in any way from performing the following daily activities- bathing, dressing, toileting, meal preparation, housekeeping, eating, managing medications, mobility?

Have you ever been diagnosed or treated by a member of the medical profession for any of the following:

Acquired Immune Deficiency Syndrome (AIDS)?

Diabetes Mellitus treated with Insulin or Arthritis treated with steroids or gold?

Alzheimer's Disease, Organic Brain Syndrome, Senility, Confusion, Disorientation, recurring Memory Loss or Dementia?

Parkinson's Disease, Multiple Sclerosis, ALS (Lou Gerhig's Disease) or internal Lupus Erythematosus?

Stroke, Congestive Heart Failure, Neurogenic Bladder, Uremia, Chronic Obstructive Pulmonary Disease (COPD), Cirrhosis of the Liver, unoperated Aneurysm or Osteoporosis?

PART TWO

During the past 5 YEARS, have you received medical advice or treatment for the following conditions? (If "yes", V those that apply):

Fractures (other than weight bearing joints)
High Blood Pressure

During the past 5 YEARS, have you received medical advice or treatment for any of the following conditions? (If yes check those that apply)

Alcoholism
Amputation
Anemia
Angina
Angioplasty
Arrhythmia
Arteriosclerosis
Arthritis (Prescription Drugs)
Bronchitis (Chronic)
Cancer (internal)
Carotid Artery Disease
Colitis
Coronary By-Pass

Coronary Insufficiency
Depression
Diabetes Mellitus
Drug or Substance Abuse
Endarterectomy
Fractures (Weight Bearing Joints)
Heart Attack
Joint Replacement
Macular Degeneration
Melanoma
Mental/Nervous Disorders
Spine or Back Disorders
Urinary Incontinence

During the past 12 MONTHS have you?

Been confined to a hospital, nursing home, or sanitarium?

Received home care services, physical or rehabilitative therapy?

Sought medical advice or treatment for loss of appetite, falling, fainting, unstable gait, bladder control, dizziness, or deterioration of vision?

Within the last 5 YEARS, have you been treated by a health professional for any condition not named above?

If yes above please list any conditions.

PART THREE

When you walk 4 blocks at a normal pace do you experience any difficulties such as shortness of breath dizziness or leg cramps?

Have you ever been treated for or diagnosed as having any of the of the following conditions: Heart Disease, Respiratory Disorder (other then Asthma or Acute Brochitis), Amputation, Joint Disorders or Replacement?

Do you now or in the past 5 YEARS used any tobacco products, including cigarettes, pipe, cigar, or chewing tobacco?

During the past 10 YEARS have you been confined to a hospital or diagnosed or treated for any of the following conditions? (If yes check those that apply)

Alcoholism
Arthritis (Prescription Drugs)
Cancer (internal)
Diabetes Mellitus
Dizziness
Drug or Substance Abuse

Epilepsy
Melanoma
Mental/Nervous Disorders
Peripheral Vascular Disease
phlebitis