noun_Checklist Document_2349387

Step Two:
Find Out If You Qualify

Fill out your Pre-Screen Form to Start the Process!

noun_assignment document_3078788

Step Three:
Design Your Custom Plan and Get Approved

Let’s Start Building Your Plan!

Once you feel like you understand your options and decide to move forward, this is your next step. Submit the Pre-Screen Form below. Then, we’ll reach out to help you choose the right options and build your custom plan.  

Your Pre-Screen Form

The form below is entirely confidential.

Our expert team uses this form to understand which plans you qualify for and which one may fit your situation the best. Once you submit it, we’ll reach out to schedule a meeting to discuss your options.

Senior couple planning their investments with long-term care advisor

Before You Submit This Form

Unfortunately, if you are taking certain medications or have been diagnosed with certain conditions, you will be uninsurable. Please refer to the list below to see if this applies to you. If you have any questions or concerns, please contact our office.

Antabuse®, Aricept®, Artane®, Avonex®, Azilect, Betaseron®, Campral®, Cogentin®, Cognex®, Comtan®, Copaxone®, Depade, Donepezil, Eldepryl®, Exelon®, Fentanyl, Galantamine, Hydergine®, Interferon®, Larodopa®/L-Dopa, Lucemyra, Memantine, Methadone, Mirapex®, Namenda®, Namzaric, Parlodel®, Permax®, Razadyne®, Reminyl®, ReVia®, Rivastigmine®, Sinemet®, Suboxone®,
Symmetrelº, Vivitrol®

Some of these medications may be considered if taking for a different reason than normally prescribed.

  • Activity of daily living deficits (need help with any of the ADL’s)
  • Alcoholism (active)
  • Alzheimer’s/Dementia
  • Amyotrophic Lateral Sclerosis (ALS)
  • Balance disorder/Gait impairment
  • Cerebral palsy
  • Cirrhosis
  • Depression (severe or hospitalized in the last 5 years) 
  • Down syndrome
  • Drug addiction/illicit drug use (within last ten years)
  • HIV positive
  • Huntington’s disease
  • Macular degeneration (progressive/wet)
  • Memory loss
  • Mental retardation
  • Multiple myeloma
  • Multiple sclerosis (MS)
  • Muscular dystrophy
  • Organ transplant (except kidney)
  • Organic brain syndrome
  • Osteoporosis with compression fracture
  • Paralysis (paraplegia/quadriplegia)
  • Parkinson’s disease
  • Pregnancy (current)
  • Stroke (multiple or residual effects)
  • Surgery pending (will review after)
  • Ventricular tachycardia

Pre-Screen Form

About You

*This is a confidential form used only to verify which long-term care insurance options you might be eligible for. This is not an application for insurance. 


Your Health


Your Spouse


Once You Choose a Plan,
There’s Just One Step Left!

noun_assignment document_3078788

3. Design Your Custom Plan, We’ll Get You Approved

You’ll be guided through designing your plan and the application process to make sure your plan is accepted.

Scroll to Top

Are you sure you want to leave?

The prescreen form has not been submitted.

Powered by Top Rated Local®