This form is the first step in the long-term care insurance planning process. This form is entirely confidential and the information is only used to make sure the experts at 525 know prior to your meeting, which plans you will qualify for and which may fit your situation best.

BEFORE Submitting this form, please refer to this section of uninsurable medication and conditions.

Unfortunately, if you have one of these conditions, even if just diagnosed or are taking any of these medications, you are not currently insurable. If you have any questions or concerns, please contact our office.


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