Wolf and Associates - Health Profile / Request Quote Form

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Health Profile / Request Quote

Our desire at Wolf & Associates is to present you with accurate information on the insurance options available to you. Previous to signing an application for long-term care insurance with any company it is difficult to determine how that company's premiums compare to that of another company with similar benefits. Consequently, our health questionnaire is intentionally detailed. More health information means increased accuracy when comparing insurance companies. Although this means a few minutes of your time now, we have found from experience that this is well worth reducing the possibility of surprises in the underwriting process. None of the rates quoted to you will be guaranteed by Wolf & Associates, Inc. and all applicants will be subject to the review of the individual insurance companies as this form IS NOT an application. However, with the information provided we will make our best attempt to give you the most accurate comparisons we can. All information will be retained by Wolf & Associates, Inc. and protected with your confidentially being of the utmost importance. None of this information will be released to any third party without your written release.

Yourself

Your Spouse

Name

Spouse Name

Email

Address

Phone

Day

Evening

Phone

Day

Evening

DOB

DOB

I Am Also Interested In Information For:

Parents/In-Laws Grandparents/In-Laws

Adult Children

Current Prescribed Medications
(Any on-going meds; current or discontinued in last five years):
Click Here For More Room

Prescription For Date From	Dosage Date To	Prescription For Date From	Dosage Date To
Prescription For Date From	Dosage Date To	Prescription For Date From	Dosage Date To
Prescription For Date From	Dosage Date To	Prescription For Date From	Dosage Date To

Hospitalizations (Last 10 years): Click Here For More Room	Hospitalizations (Last 10 years): Click Here For More Room
Date Condition Outcome	Date Condition Outcome
Date Condition Outcome	Date Condition Outcome
Date Condition Outcome For More Space Click Here.	Date Condition Outcome For More Space Click Here.

Past Heart History (HTN, arrhythmia, CHF, angioplasty, bypass, etc): Click Here For More Room	Past Heart History (HTN, arrhythmia, CHF, angioplasty, bypass, etc): Click Here For More Room
Date Type Outcome	Date Type Outcome

Past Cancer History Click Here For More Room	Past Cancer History Click Here For More Room
Date Type Outcome	Date Type Outcome

On-Going Treatments (Including chiropractic & physical therapy):	On-Going Treatments (Including chiropractic & physical therapy):
Date Type Outcome	Date Type Outcome

Bone Density Tests	Bone Density Tests
Yes No (Scores, if known):	Yes No (Scores, if known):

Tobacco (Check one):	Tobacco (Check one):
Yes No If discontinued, for how long?	Yes No If discontinued, for how long?

Self Information	Spouse Information
Height Weight Date of last physical	Height Weight Date of last physical

This information is confidential

Continued Information
Use the fields below to provide more information if needed.

Current Prescribed Medications (cont.) Back		Current Prescribed Medications (cont.) Back
For Date From	Dosage Date To	For Date From	Dosage Date To

For

Date From

Dosage

Date To

For

Date From

Dosage

Date To

For

Date From

Dosage

Date To

For

Date From

Dosage

Date To

Hospitalizations (cont.) Back	Hospitalizations (cont.) Back
Date Condition Outcome Date Condition Outcome Date Condition Outcome	Date Condition Outcome Date Condition Outcome Date Condition Outcome
Past Heart History (cont.) Back	Past Heart History (cont.) Back
Date Type Outcome Date Type Outcome Date Type Outcome	Date Type Outcome Date Type Outcome Date Type Outcome
Past Cancer History (cont.) Back	Past Cancer History (cont.) Back
Date Type Outcome Past Cancer History (cont.) Date Type Outcome Past Cancer History (cont.) Date Type Outcome	Date Type Outcome Past Cancer History (cont.) Date Type Outcome Past Cancer History (cont.) Date Type Outcome

501 North Riverpoint Boulevard, Suite 230
Spokane, Washington 99202
(509)744-7065
1-800-721-2188
fax: (509)744-7068