This
questionnaire is offered only as a GUIDE to help clairify
one's POSSIBLE need for long-term care insurance.
1.
While everyone is at risk for he services provided
by long-term care professional, not all people ahve
the ability to pay for these services or pay for the
premium of a long-term are insurance policy. The following
questions will help determine your financial risks
and premium paying ability.
If
you are single, do you have over $75,000 of assets?
Select One
Yes
No
If
you are single, is your annual income for ALL
sources over $24,000?
Select One
Yes
No
If
you are married, do you have over $75,000 of assets
excluding your home?
Select One
Yes
No
If
you are married, is your annual income from ALL
sources over $40,000?
Select One
Yes
No
If
you have children, would they be able to share
in the costs of your LTC insurance policy?
Select One
Yes
No
2.
Some people might consider self-insuring. If you have
a large amont of assets, you may prefer to pay for
the cost of nursing care out of your savings.
For
example, the cost of nurisng homes in the Northeast
can range from $55,000 to $100,000 per year. If
you (r yor spouse) needed nursing home care, would
spending this much per year for Long-Term Care
cause a significant change in your lifestyle?
Select One
Yes
No
If
married, is it of significant importance that
your spouse retain most of your assets?
Select One
Yes
No
Is
it of significant importance that you leave an
inheritance for your children or heirs?
Select One
Yes
No
3.
Informal care, provided by your family or friends,
can postpone and possibly eliminate the need of paid
care.
Do
you have family or friends living with you or
close to you who would provide assistance?
Select One
Yes
No
Would
you feel comfortable having to ask them for assistance?
(Examples: Managing medications, dressing, meal
preparation, feeding, toileting, etc.)
Select One
Yes
No
Could
they afford to take time away from work in order
to provide you assistance?
Select One
Yes
No
Could
they afford to take time away from their family
in order to provide you assistance?
Select One
Yes
No
Could
you move in with them?
Select One
Yes
No
Would
you ant to move in with them?
Select One
Yes
No
Could
they bathe you?
Select One
Yes
No
Could
they lift you up from a chair or bed?
Select One
Yes
No
Could
they carry you out of the house?
Select One
Yes
No
4.
How you feel about "Choice" will also determine
if long-term care insurance is right for you.
Welfare
(Medicaid) was designed as the last resort for
widows and children with no other place to turn.
Yet, some people hide their assets in Irrevocable
Trust to qualify for welfare. (1993 Medicaid rules
for trusts created a 60-month look-back period,
for transfers.) Do you feel people with means
have an obligation to pay for their own nursing
care costs?
Select One
Yes
No
In
order to qualify for welfare, one must spend down
all their assets to the poverty level and relinquish
most of their income. Would this matter to you?
Select One
Yes
No
On
welfare (Medicaid), nursing home care can be rendered
up to a 50-mile radius from your home. Would this
matter to you?
Select One
Yes
No
5.
Health history is an important factor in qualifying
for LTC insurance. Although insurance companies do
not expect you to have the health of a 20-year-old,
they do want you to be in "fairly" good
health for your age.
Are
you dependent on the use of a walker or wheelchair
or confiend to bed or home?
Select One
Yes
No
Is
your spouse dependent on the use of a walker or
wheelchair or confined to a bed or home?
Select One
Yes
No
Do
you use any medical appliance such as a catheter,
oxygen, respirator, or dialysis machine?
Select One
Yes
No
Does
your spouse use any medical appliance such as
a catheter, oxygen, respirator, or dialysis machine?
Select One
Yes
No
In
the past TEN years, have you, (or your spouse),
been hospitalized for any reason?
Select One
Yes
No
If
"YES", list the name of the person
who had the hospital stay, the reason for
thestay and the date of the hospital stay(s).
In
the past TEN years, have you, (or your spouse),
taken a prescribed medication?
Select One
Yes
No
If
"YES", list the name of the person
taking the medication, the complete name of
the medication, the amount taken per day,
and the purpose for taking the medication.
In
the past FIVE years, have you, (or your spouse),
seen a medical doctor?
Select One
Yes
No
If
"YES", list the name of the person
who saw the doctor and the reason for seeing
th doctor.
In
the past FIVE years, have you, (or your spouse),
used any tobacco products, including cigarettes,
pipe,cigar, or chewing tobacco?
Select One
Yes
No
If
"YES", please list who used or uses
tobacco products.
What
is your height and weight?
(height)
(height)
The
dollar value of the assets you wish to protect:
$
