Pre-Qualifying Health Questionnaire

Tobe Gerard Insurance, LLC uses JotForm to collect your health information as safely as possible.
Name *

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred phone number to contact you. *

Area Code Phone Number
Preferred email to contact you. *
example@example.com
Date of Birth *

Month Day Year
Date
Height (inches) *
Weight (lbs) *
Do you have a partner/spouse with whom you live? *

Yes No

When was your most recent annual physical with your PCP? *

Month Day Year
Date
When was your last full panel of blood work with your PCP? *

Month Day Year
Date
Please list all medications you are currently taking including dosage, reason for taking, and for approximately how long: *

Do you currently have HIV/AIDS? *

Yes No
Unfortunately, you are not eligible for coverage at this time.
Do you have ALS, Cirrhosis, Cystic Fibrosis, Huntington’s Chorea, Kidney Disease, Memory Issues, Muscular Dystrophy, Multiple Sclerosis, Parkinson’s, Schizophrenia, Systemic Lupus? *

Yes No
Unfortunately, you are not eligible for coverage at this time.
Do you currently use: Cane, walker, wheelchair, electric scooter, stairlift, hospital bed, nebulizer, or oxygen? *

Yes No
Unfortunately, you are not eligible for coverage at this time.
Do you currently receive: Benefits under Disability Income, Medicaid, Social Security Disability, or Workers Compensation? *

Yes No
Unfortunately, you are not eligible for coverage at this time.

Other
Have you looked at long term care insurance previously? *

Yes No
Are you presently looking at long term care insurance with another source? *

Yes No
Have you been declined for long term care insurance? *

Yes No
Who referred you to us? *
NOTE: Please make sure to click SUBMIT above to ensure your information has been sent. You will receive an email confirmation a few minutes later which confirms your entry was submitted.
Should be Empty:

Family History