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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
Home
Quick Quote Form
Personal Lines Quote Form
Special Insurance Programs
Churches
Contractors
Farm & Ranch
Restaurants
Teen Driver Insurance Program
Realtor Errors and Omissions
Health Insurance
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