New York & National Long Term Care Brokers: Services

Information Form
Many people would like to know if we can help them with their long-term care planning. The following form will provide us with information about you to help us in our initial evaluation about your specific long-term care insurance needs. If you do not wish to complete this form, but would like some information, click here to go to our simplified contact us form.
About yourself and family

Your name		Date of birth
Spouse		Date of birth

Contact Information
Address
City
State
Zip
E-mail
Phone

Children
1.Name
	Location
	Age

2.Name
	Location
	Age

3.Name
	Location
	Age

4.Name
	Location
	Age
Current or former occupation:
Husband
Wife

Retirement date if applicable
Husband
Wife

Family History

Yours
		Father	Mother
Age of living
Cause of death
Needed LTC?		yes no	yes no
Cause of LTC

Your Spouses
		Father	Mother
Age of living
Cause of death
Needed LTC?		yes no	yes no
Cause of LTC

Health history
Health Conditions
	Your health history		Your Spouse's health history



Activities
	1 2 3 4 5		1 2 3 4 5
Risk factors
		You	Spouse
Smoking?		yes no	yes no

Year you quit:

Packs per day



Visit New York Partnership for Long Term Care

National/New York Long-Term Care Brokers . 11 Executive Park Drive Clifton Park, NY 12065-5631
518 371-5522 / 800 695-8224 FAX 518 371-6131