Bestplans Canada: Long Term Care Quote Form

Long Term Care Quote Form

Request a free Long Term Care price quote comparison

Section A: Medical History
*1. Do You Currently:*
a. Use or require the use of any mechanical devices such as: a wheelchair, walker, multi-prong cane, crutches, hospital bed, dialysis, oxygen, motorized cart or stairlift?			Yes No

b. Need help, assistance or supervision in doing any of the following: bathing, eating, dressing, toileting, walking, transferring or maintaining continence?			Yes No

c. Need help, assistance or supervision in performing two or more of the following everyday activities: taking medication, doing housework, laundry, shopping or meal preparation?			Yes No

*2. Have you ever been diagnosed with, treated or been advised to be treated for:*
a. Cancer which has spread from the original site or organ?			Yes No

b. Amputation due to disease or medical condition?			Yes No

c. Memory loss, senility or dementia?			Yes No

d. More than one stroke or transient ischemic attack (TIA)?			Yes No

e. Alzheimer’s, Parkinson’s, Lou Gehrig’s Disease (ALS), Motor Neuron Disease, Muscular dystrophy, Huntington’s Chorea, and/or multiple sclerosis?			Yes No

f. Acquired immune deficiency syndrome (AIDS), AIDS related complex, AIDS related conditions or tested positive for HIV			Yes No

g. Liver cirrhosis or renal failure			Yes No

h. Diabetes or chronic lung diseases			Yes No

Section B: Your Information (Please complete the following only if you answered "No" to all of the questions in Section A.) Fields marked with an * are required fields.
Salutation:		Gender:	Male Female
*First Name:		*Last Name:
*Address 1:		Address 2:
*City:		*Province:	*PC:
*Phone:		Fax:
*Email:		DOB:	/ /
Height:	' " ft cm	Weight:	lbs kg

Have you used any form of tobacco in the last 24 months?			Yes No

Comments:


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