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 *

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
Should be Empty:

Family History