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Joint LTC Request for Proposal

Person A: Name(Required)
Person B: Name(Required)
Person A: Birth Gender(Required)
Person B: Birth Gender(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Person A: Have you ever used tobacco, nicotine, marijuana, CBD Oil, do you vape, use e-cigarettes or smokless tabacco?(Required)
Person B: Have you ever used tobacco, nicotine, marijuana, CBD Oil, do you vape, use e-cigarettes or smokeless tobacco?(Required)
Person A: Have you ever been declined for Long Term Insurance?(Required)
Person A: Have you ever been confined to a nursing or rehabilitation facility or needed assistance with any activities of daily living?(Required)
Person B: Have you ever been declined for Long Term Insurance?(Required)
Person B: Have you ever been confined to a nursing or rehabilitation facility or needed assistance with any activities of daily living?(Required)
Person A: Have you ever been diagnosed or treated for any of the following:
Person B: Have you ever been diagnosed or treated for any of the following:
Person A: In the last 12 months, have you received or are you currently receiving physical therapy or care from a chiropractor?
Person A: Have any surgeries been recommended or referrals to a specialist that have yet to be completed?
Person B: In the last 12 months, have you received or are you currently receiving physical therapy or care from a chiropractor?
Person B: Have any surgeries been recommended or referrals to a specialist that have yet to be completed?
Person A: Do you have any family history (mother, father, brother, or sister) with alzheimer's, dementia, coronary artery disease, etc.)
Person B: Do you have any family history (mother, father, brother, or sister) with alzheimer's, dementia, coronary artery disease, etc.)

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Gallagher Affinity Insurance Services, Inc., provides administrative support services to insurance plans sponsored by associations and fulfilled by insurance carriers. Our support includes certificate issuance and facilitation of information in support of applications and claims for benefits provided by the insurance carrier. The carrier fulfills the benefit determination and any payments on claims associated with those benefits. Insurance brokerage and related services to be provided by Gallagher Affinity Insurance Services, Inc. (License No. 100310679 | CA License No. 0783129).

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