Personalized LTC Insurance Quote

Home Health Care and Long-Term Care are generally not covered by health insurance or Medicare. With facility costs approaching $300/day in certain areas, and round-the-clock home health care nearing that same level, Home Health Care/Long-Term Care insurance could make the difference between a secure financial future or the loss of hard-earned assets. CRC employees, spouses, parents, grandparents and adult children can now receive special discounts on this vital coverage.

Part I Contact Information ( all fields marked with an * must be filled in to continue)

First Name *

Last Name *

Email Address *

Confirm Email *

Phone Number *

use format xxx -xxx-xxxx

Best Time to Call

Street Address *

Apt. #

City *

State

Zip*

Part II Your Information

I would prefer to provide my personal information by phone, not by internet. Please contact me.

If Providing Information Via Internet Only:

Name	Relationship	Date of Birth	Sex	HT?	WT?	Smoker?
			M F			Y N
			M F			Y N
			M F
			M F
			M F

Medical Questions:

1. In the past 10 years have you or any member to be quoted been medically diagnosed with or treated for:

AIDS or positive HIV status, Alzheimer's Disease or dementia, Amyotrophic Lateral Scleroses, Multiple Sclerosis, Muscular Dystrophy, Myasthenia Gravis, Organic Brain Syndrome, Parkinson's Disease or Parkinsonism, Lupus Erythemotsis or Scleroderma?

2. In the past 10 years have you or any member to be quoted been medically advised or treated for :

Abnormal blood pressure, heart or circulatory disorder, diabetes, asthma, emphysema or other chronic respiratory disorder, cancer; internal or melanoma, skin cancer other than melanoma, stroke, TIA ( transient ischemic attack),amnesia, paralysis, any form of neurological disorder, cirrhosis of the liver, alcohol or drug dependency or abuse, arthritis or osteoporosis, depression or other psychiatric disorder, seizures or other brain disorder, kidney, prostate, breast or other genito- urinary disorder, glaucoma or macular degeneration?

If Yes Which Condition?

During the Past 12 months have you or any member to be quoted been advised to have surgery that has not yet been performed?

If Yes Please provide details:

During the past 12 months have you or any member to be quoted taken any prescription medications?

Family Member's Name	Name Medications Prescribed	Dosage taken	How many times taken daily	Taken From Date	Taken To Date

Questions/Comments

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WORLDWIDE INSURANCE SERVICES, INC.
237 Melvin Drive
Northbrook, IL 60062