noun_Checklist Document_2349387

Step Two:
Submit a Pre-Screen Form

Find out what long-term care plans you qualify for.

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

Read This First!

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
  • 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

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®