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*

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

YesNo

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

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

MonthDay 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?*

YesNo
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?*

YesNo
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?*

YesNo
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?*

YesNo
Unfortunately, you are not eligible for coverage at this time.

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

YesNo
Are you presently looking at long term care insurance with another source?*

YesNo
Have you been declined for long term care insurance?*

YesNo
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