VA - Confidential Long Term Care Questionnaire

Confidential Long Term Care Questionnaire

Name:	_______________	Date Of Birth:	_______________
Spouse:	_______________	Date Of Birth:	_______________
Address:	_______________
Home Phone:	_______________	Business Phone:	_______________

	Assets you own that are income producing		Income that you can count upon
Real Estate	_______________		_______________
Securities	_______________		_______________
CD's & Savings	_______________		_______________
Rental Property	_______________		_______________
Other Income Producing Property	_______________		_______________

Pension (Husband) When does it end?		_______________
Pension (Wife) When does it end?		_______________

Do you have any	Relatives, Friends or Neighbors who have needed Long Term Care or Home Health Care?
Can you visualize	Yourself or your Spouse in need of Long Term Care or Home Health Care?
Can you qualify?	Been Declined for Insurance? Hospital Confinements? Chronic Illnesses? Medications?

Do you own any Long Term Care insurance now?

Children, Friends, Relatives:

Do they live nearby?
Can you count upon them as Caregivers?
Can they assist you financially?
Do you want to have to ask them to do so?
Should they be involved in helping you decide upon
the purchase of Long Term Care insurance?

The True Cost of	$300/day in New York is not unusual.
Long Term Care	(That's over $100,000/year)

At that rate how long would it take to destroy your Life's Savings and put you and your Spouse (or Widow) on Welfare?

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