The Allenbrook Agency
clientFIRST Insurance Solutions
 
 

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Mike

  “I have worked with Don for over 4 years now and have always been impressed with his product and industry knowledge as well as his enthusiasm for helping others. I have not only referred clients and friends to Don, but also trust him with my personal insurance needs.”
 
 

 
Request For Long Term Care Proposal
Your Contact Information
 Type Of Request  
 Currently Insured With Us?
Best Number To Reach You?  
Your Email Address  
Street Address  
City  
State  
Zip Code  
 

Your Information
First and Last Name    
Date Of Birth (mm/dd/yyyy)
Height (' feet and " inches)
Weight (pounds)
Are You Retired
Occupation  
Business Owner  
Type Of Business  
     
Please List All Prescription Medications
with Dose
and Frequency
and What It Is Prescribed For

   

Spouse's Information

  
First and Last Name    
Date Of Birth (mm/dd/yyyy)
Height (' feet and " inches)
Weight (pounds)
Are You Retired
Occupation  
Business Owner  
Type Of Business  
     
Please List All Prescription Medications
with Dose
and Frequency
and What It Is Prescribed For


Have You or Your Spouse Ever Been Treated For Any Of The Following Within Last 5 Years?
 
  You Spouse

1.  Ever been Declined for Long Term Care insurance?
2.  Smoked or used Tobacco products (patches)within last 5 Years?
3.  High Blood Pressure?
3a. Has it been controlled for over 6 months?
 4. Heart Attack, Angina, Angioplasty or Arterial Fibrillation?
4a. Date Diagnosed (mm/dd/yyyy)?
5. Stroke or TIA?
5a. Date Diagnosed (mm/dd/yyyy)?
6.  Arthritis (Rheumatoid, Osteo)?
7.  Diabetes (Type I Insulin Dependent?
7a.  Diabetes with Neuropathy or Retinopathy?
9.  Osteoporosis?
9a. T-Score?
9b.  Compression Fractures?
10. Cancer?
10a. Type?
10b. Stage?
10c. Last Treatment (mm/dd/yyyy)?
11. Receiving Social Security or Disability Benefits?
12. Any Other Medical Conditions Not Listed Above?
12a. If You Answered Yes To Other Medical Conditions
Please List?
 

 

 
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"The Allenbrook Agency" and "clientFIRST" are Registered Service/TradeMarks
The Allenbrook Agency
3091 South Newcombe Way  Lakewood, Colorado 80227
     303.225.3298

For Immediate Claims Assistance Please Call Farmers Help Point At 1-800-435-7764