Long-term care insurance is highly individualized according to a client's health, asset base, and income. A one-size-fits-all approach is not the answer. Ohio Long Term Care Brokers specializes in pre-qualifying your client with an LTC carrier, thereby saving you time by decreasing the likelihood of declined and/or rated cases. The following pre-certification form will allow us to evaluate your client's current health status. We will then find the most suitable company with respect to underwriting and best value for your client. Please fill this form out completely and accurately. You may email it or fax it to our office for a quote. We will provide quotes from the top three LTC carriers your client qualifies for within 24 hours. If a faster turnaround is required, we recommend that you call our office and speak to one of our representatives. Your quotes can be emailed, faxed or mailed to you. Please indicate which method of delivery you wish and provide the appropriate information (i.e., email address, fax number, etc.) to expedite delivery of your quotes.

          

     One of the biggest mistakes that agents make in the long-term care business is assuming that the client is healthy and takes no medications. This is a rarity. BE VERY SPECIFIC in gathering information on your client's health. The following are a few pertinent questions to ask your client before requesting a quote for long-term care:

          

If you would rather fax or mail the quote form, you can find a Printable Version Here

Agent Name:
Agent's Phone:
Agent's Fax:
Agent's Email:

Client

Name: Date of Birth: Gender Male Female

Height: feet, inches. Weight: pounds      Smoker? Yes No

Have you been in the Hospital in the Last 5 years?
(If yes, please provide details)

Do you have any personal history of: Stroke Diabetes Cancer
(If yes, please provide details)

Name of Medication(s), Dosage, and what Conditions it Treats:

Spouse

Name: Date of Birth: Gender Male Female

Height: feet, inches. Weight: pounds      Smoker? Yes No

Have you been in the Hospital in the Last 5 years?
(If yes, please provide details)

Do you have any personal history of: Stroke Diabetes Cancer
(If yes, please provide details)

Name of Medication(s), Dosage, and what Conditions it Treats:

Daily Benefit:

Home Health Care:

Benefit Period:

Elimination Period:

Inflation:

Additional Information/Comments: