Long-Term Care Intake | Michael Fox Insurance

Who you are

Basic contact info so Michael can follow up.

Full legal name *

Preferred name

Email *

Best phone number *

Date of birth *

State of residence *

Best time to reach you

Marital & household

Is a spouse/partner also applying?

No

Yes — together (couples discount)

Many carriers offer 15–30% discounts when both partners apply.

Spouse/partner name (if applying)

Spouse/partner date of birth

Coverage design

We'll fine-tune; rough preferences are fine.

Type of LTC coverage you're considering *

Target monthly benefit

Benefit period

Elimination (waiting) period

Inflation protection

5% compound is gold standard but increases premium.

Premium budget (monthly or annual)

Preferred premium structure

Lifetime pay (lowest annual)

10-pay

Single premium (one lump)

Not sure

Existing LTC or long-term care planning

Do you currently have LTC or hybrid coverage? *

No

Yes — traditional LTC

Yes — hybrid life/LTC

Yes — annuity/LTC

Carrier (if any)

Current daily/monthly benefit

Current premium

Ever been declined or postponed for LTC or disability coverage? *

No

Yes — will explain

If declined/postponed, when and why?

Build & basic health

Sex as listed on government ID *

Height *

Weight (lbs) *

Primary care doctor (name & city)

Date of last physical

Cognitive & mobility — LTC underwriting cares deeply about these

LTC underwriters are stricter on cognition and mobility than life insurance. Honest answers help us place you with the right carrier.

Medical history

Financial picture

Suitability matters — LTC carriers want assurance the premium fits your retirement plan.

Annual household income (incl. Social Security/pension) *

Liquid assets (cash, brokerage, CDs) *

Retirement assets (401k, IRA, 403b)

Approximate home equity

Beneficiary & ownership

Primary beneficiary (for hybrid death benefit)

Contingent beneficiary

Anything else

Anything else underwriters should know, or questions for Michael?