All Things Insurance Benefits

Regina Wagner, CLTC® 832-699-2245

Long Term Care & Extended Care Insurance Planning Questionnaire

Who Referred Us To You? *

First Name *

Last Name *

Email *

Cell Phone *

Address 1

Address 2

City *

State *

Postal code *

Your Gender? *

Date of birth *

A little about me, Regina Wagner, ….I have 28 years insurance experience, helped my parents over 25 years ago with a plan that paid out close to $300k before mom passed with Alzheimer’s. Can not imagine what would have happened if we did not have the protection of a LTC insurance.

I am an independent broker AND I am licensed with the Top rated insurance carriers offering affordable prices, and my job is to help you achieve your goal to see if long term care insurance is a fit for you. We are a ONE STOP shop!

We help people with low budgets, those with middle of the road budgets, and those with significant assets to protect.

I'm curious what got you looking into long term care insurance today? Are you looking for just you or you and someone else? Any experience with Family/Friend needing care? Have you looked in the past? Reason you did not put a plan in place? *

Everyone should have a Long Term Care Plan, However; Long term care insurance is not for everyone, you have to qualify based on health and finances. Did you know there was a health and financial qualification?

Great news! There are a ton of ltc solutions, ( We do ALL the research for you at NO COST - My job is to know and understand the 3 types of plans (Traditional LTCi, hybrids, and alternative care and help recommend a plan....over 28 companies - Remember WE ARE A ONE STOP SHOP!!!) and in order for me to determine which solution is the best for you and your goals I have to ask some health and financial questions.

Every question I ask has a purpose of helping me select the best solution for you and your goals.

Let's get started.

Most people fall in 1 of 2 categories; 1. Had Experience and Looking for a plan 2. Just looking for information. Which Category are you in? What's your goal or what are you hoping to accomplish by meeting with me today? *

Emergency Contact Name, Cell Number, Relationship *

Do you have children? *

Yes

If YES, what are their First Names? Ages? State They Live? Which child will likely be the care coordinator? Where do you want to receive care? Which of your family members would likely be your caregiver and decision maker for your care? Do you prefer professional caregiver or family caregiver? Do they Know? Where do you want to receive care? Do you have Will/Trust/POA/Health Directive?

Have you (or Spouse if applicable) been hospitalized/outpatient procedures/emergency room visits? in the last 10 years? *

Over Your Lifetime have you (or spouse/partner if applicable) had any of the following? Cancer, Stroke, heart attack, diabetes, arthritis, uncontrolled blood pressure, heart disease, kidney failure, daily oxygen, anxiety/depression, mobility issues with bones or joints, Parkinsons, Alzhiemer's, Multiple Sclerosis, Physical Therapy, Use of assistive devices like walker, cane, wheelchair, hospital bed, respiratory/COPD, chronic bronchitis, asthma, sleep apnea, cpap, Assistance with ADLs, recent home health, skilled nursing care?...Or Anything like that? *

If YES, provide details like When? How Long? How Treated?

Please list all MEDICATIONS you are currently taking & previously taken in last 2 years including dosage, reason for taking, and for approximately how long: If not currently taking medication, please write "None" in the "Name of Medication" field below. Any medications prescribed in last 2 years, but not taking or was discontinued.

Medication name, dosage, reason taken, and how long? Any Rx changes?

Tobacco User? Last 2 years? *

What is Your Actual Height? *

What is Your Actual Weight? *

Have you or (spouse/partner if applicable) had a PHYSICAL in LAST 2 Years? *

Give DATE of last Exam with FULL BLOOD PANEL *

Other Health Issues in MEDICAL RECORDS? IF YES, PROVIDE DETAILS

Ever been DECLINED FOR Life, Health, or Long Term Care Insurance? *

If Yes to DECLINE, Provide details

Clean Driving Record? *

Receiving disability? Medicaid? or Using Handicap stickers? *

If yes to disability, medicaid, or handicap stickers, provide details

Biological Family History: Cancer, Alzheimer's, Dementia, Parkinson, Heart Attack, or Stroke? *

If Yes, Biological Family History, provide details

Financial Advocates recommend people with assets to purchase LTCi to protect those assets. FINANCIAL suitability is just as important as HEALTH suitability. this will help me recommend a plan that fits your budget as well as your needs. And we don't want you to over insure.

Do you own or rent your home? *

Not including your home, Approx Networth? Do You Have $50K or more in retirement savings/investments? *

Monthly Income? Monthly Expenses? Discretionary Income? What's your Budget? *

Do You Own A Business?

If Yes, Provide Business Name and Type

Retirement Assets (401k? Pensions? Annuities? IRAs? Life Insurance with Cash Value?) If something happened that required 6 months or longer to recover, which asset will you liquidate first?

Most people want to PROTECT family, PROTECT assets, and/or PROTECT choices and independence. What would YOU like to protect? *

NEXT STEPS: I will do the research to find the best LTC solutions at the best price. We are independent Brokers and a ONE STOP SHOP! Which means I work with all the top LTCi companies that offer solutions. I will be shopping all the carrier options for you. One of the companies I work with is a fraternal organization. This means that they are an organization that offers their products to those who share a common bond. Their common bond is a faith rooted in Christianity.

Would you say that you or spouse/partner have a faith based in Christianity or would this company not be a good fit for us to consider when shopping out your options *

Looking for plan details and plan costs? I use the answers to the above questions when researching plans and when making plan recommendations. IF I FIND A PLAN THAT FIT YOUR NEEDS AND BUDGET, ARE YOU PREPARED TO APPLY? (THIS DOES NOT GUARANTEE A PLAN HOWEVER IT LOCKS IN YOUR AGE AND HEALTH) IF NO, "MAY I ASK WHAT'S HOLDING YOU BACK?" Let's get you scheduled for our next meeting. *** Do we need to invite anyone to this meeting? Spouses, children, etc? Please call our office if you will be unable to keep your scheduled appointment.

Any plans in the next 12 months for medical test/treatment/procedure? Colonoscopy?mammogram? Exam? etc *

If Yes, pending TESTS/TREATMENT/PROCEDURES/EXAMS - GIVE DETAILS

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This LTCi Form Was Completed By: *