Long Term Care Quote Form

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Long Term Care/Health Care Cost Assessment Fact Finder

Complete for a Free No-Obligation customized health care cost and long term care analysis proposal from The Hanks Group

* Indicates required field

Client Name *

First

Last

Gender *

Male Female

Date of Birth *

Retirement Age *

Home Address *

Phone Number *

Email *

Spouse Name *

First

Last

Gender *

Male Female

Date of Birth *

Retirement Age *

Client Assessment Questions

Diagnosed with high blood pressure? *

Yes No

Diagnosed with high cholesterol? *

Yes No

Diagnosed with type 1 diabetes *

Yes No

Diagnosed with type 2 diabetes *

Yes No

Diagnosed with cardiovascular disease? *

Yes No

Diagnosed with cancer? *

Yes No

Diagnosed with multiple sclerosis? *

Yes No

Currently a tobacco user? *

Yes No

Dependent on a cane, walker or wheelchair? *

Yes No

Exercise for at least 2 hours a week? *

Yes No

Follow a healthy well-balanced diet? *

Yes No

Family history of diabetes or cardiovascular disease? *

Yes No

Spouse Assessment Questions

Diagnosed with high blood pressure? *

Yes No

Diagnosed with high cholesterol? *

Yes No

Diagnosed with type 1 diabetes *

Yes No

Diagnosed with type 2 diabetes *

Yes No

Diagnosed with cardiovascular disease? *

Yes No

Diagnosed with cancer? *

Yes No

Diagnosed with multiple sclerosis? *

Yes No

Currently a tobacco user? *

Yes No

Dependent on cane, walker, or wheelchair? *

Yes No

Exercise for at least 2 hours a week? *

Yes No

Follow a healthy well-balanced diet? *

Yes No

Family history of diabetes or cardiovascular disease? *

Yes No

Annual Income in Retirement
(your estimated income post retirement, not your income level before retirement)

Married filing jointly: for married couples filing a joint tax return

Client and Spouse *

$170,000 or less $170,001 to $214,000 $214,001 to $320,000 $320,001 to $428,000 more than $428,000

Married filing separately: for married couples filing separate tax returns

Client *

$85,000 or less $85,001 to $129,000 more than $129,001

Spouse *

$85,000 or less $85,001 to $129,000 more than $129,001

Individual: for single persons filing an individual tax return

Client *

$85,000 or less $85,001 to $107,000 $107,001 to $160,000 $160,001 to $214,000 more than $214,001

Submit

6300 Samuel Blvd Suite 105 Dallas, TX 75228 214-275-8372 Office
2100 N Main St Suite 105 Fort Worth, TX 76164 817-557-0915 Office

Home
Quick Quote Form
- Personal Lines Quote Form
Special Insurance Programs
About Us
Contact Us
Insurance Blog By Rod
Privacy Statement
10 Stupid Easy Ways to Save a Lot of Money on Car Insurance
Realtor E and O Quote Page
Seniors
Online Auto Quote

Long Term Care/Health Care Cost Assessment Fact Finder

Client Assessment Questions

Spouse Assessment Questions

Annual Income in Retirement (your estimated income post retirement, not your income level before retirement)

Annual Income in Retirement
(your estimated income post retirement, not your income level before retirement)