Long Term Care Information Request Form

Please complete the following:

Name:

Address:

City:

State:

Zip Code:

Phone Number: Best Time to Call:

Email Address:

Birthdate:

Do you have a spouse, sibling, partner living in the same household with you? Yes No

If you answer "yes" to any of the following, then we suggest not continuing with this process, as we will be unable to offer coverage:

1. Do you currently have, or have you ever had a diagnosis for: Alzheimer's Disease, Huntington's Chorea, Multiple Sclerosis, Schizophrenia, Amyotrophic Lateral Sclerosis, Memory Loss, Muscular Dystrophy, Scleroderma, Cystic Fibrosis, Mental Retardation, Myasthenia Gravis, Spinal Cord Injury, Dementia, Multiple Myeloma, Parkinson's Disease Stroke/CVA? Yes No

2. Do you currently require human assistance or supervision in any of the following activities: eating; dressing; toileting; transferring from bed to chair; walking maintaining continence; or bathing? Yes No

3. Do you currently reside in, have you been advised to enter, or are you planning to enter a nursing home, assisted care living facility or other custodial facility, or are you currently receiving home health care services or attending adult day care? Yes No

4. Do you currently use one of the following medical devices: wheelchair; walker; hospital bed; quad cane; oxygen; stairlife; or dialysis? Yes No

5. Have you been diagnosed or treated by a member of the medical profession for AIDS (Acquired Immune Deficiency Syndrome) or AIDS Related Complex? Yes No

Option 1
$6,000 per month benefit¹, 100 day elimiation period, 5 year benefit plus a million dollars², waiver of home health care, compound inflation tied to the consumerprice index.

Option 2
$4,500 per month benefit¹, 100 day elimination period, 5 year benefit plus a million dollars², waiver of home health care, compound inflation tied to the consumer price index.

Option 3
$3,000 per month benefit¹, 100 day elimination period, 5 year benefit plus a million dollars², waiver of home health care, compound inflation tied to the consumer price index.

¹ We advise that you visit http://www.johnhancocklongtermcare.com/index.jsp?cid=03089, select your state and click on the Interactive Cost of Care map to determine your necessary monthly benefit.

² 5 years is the length of time your insurance will last if you receive care every day at a cost equal to or more than your daily maximum benefit amount. If your care costs less, your insurance will last longer than the benefit period. The benefit period is used together with your daily maximum benefit amount to calculate your lifetime maximum benefit. If you are on claim for a total of 60 months you will be eligible for a secondary benefit pool of one million dollars.

If you have any questions or need assistance, please feel free to contact us at 800.524.4091 or via e-mail at ltc@nesbitagencies.com.

1. Do you currently have, or have you ever had a diagnosis for: Alzheimer's Disease, Huntington's Chorea, Multiple Sclerosis, Schizophrenia, Amyotrophic Lateral Sclerosis, Memory Loss, Muscular Dystrophy, Scleroderma, Cystic Fibrosis, Mental Retardation, Myasthenia Gravis, Spinal Cord Injury, Dementia, Multiple Myeloma, Parkinson's Disease Stroke/CVA?	Yes No
2. Do you currently require human assistance or supervision in any of the following activities: eating; dressing; toileting; transferring from bed to chair; walking maintaining continence; or bathing?	Yes No
3. Do you currently reside in, have you been advised to enter, or are you planning to enter a nursing home, assisted care living facility or other custodial facility, or are you currently receiving home health care services or attending adult day care?	Yes No
4. Do you currently use one of the following medical devices: wheelchair; walker; hospital bed; quad cane; oxygen; stairlife; or dialysis?	Yes No
5. Have you been diagnosed or treated by a member of the medical profession for AIDS (Acquired Immune Deficiency Syndrome) or AIDS Related Complex?	Yes No