Form Ltc-1028 - Jh Ltc Prequal Form
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1Underwriting Prequalification Form
Complete this form and fax it to our Prequalification Team at 617-450-8052, to receive a preliminary underwriting opinion within 24 hours. If you
would like to obtain a verbal opinion, please call the Prequalification Team at 888-604-7296, Option 3. Please submit a copy of this form along
with our preliminary opinion when submitting the LTC insurance application. Note: The applicants’ signature and medical records are not required.
Applicant’s Date of Birth: ______________________
1. Height: ______________ Weight: ____________
2. Has the applicant used tobacco products in the last 12 months?
Yes
No
3. Within the last five years, have you received medical advice, diagnosis, or treatment, or consulted with a member of the medical
profession for any of the following conditions:
Circulatory disorders
Yes
No
Endocrine and pituitary disorders
Yes
No
Cancers
Yes
No
Genital urinary disorders
Yes
No
Gastrointestinal disorders
Yes
No
Neurological disorders
Yes
No
Blood disorders
Yes
No
Musculoskeletal disorders
Yes
No
Respiratory disorders
Yes
No
Eye and ear disorders
Yes
No
Substance abuse
Yes
No
4. Does the applicant currently use any assistive or mechanical devices?
Yes
No
5. Has the applicant ever received home health care, been confined to a nursing home, or rehabilitation facility?
Yes
No
6. Does the applicant require human assistance or supervision in performing any of the activities of daily living?
Yes
No
7. Has the applicant consulted with their primary care physician within the past 18 months?
Yes
No
8. Does the applicant currently receive disability benefits? If yes, list type of disability and medical condition.
Yes
No ___ Disability %
______________________________________________________________________________________________________
Details to questions 3–6:
Q# ___ Diagnosis __________________________ Diagnosis date _____________________ Treatment dates ______________
Q# ___ Diagnosis __________________________ Diagnosis date _____________________ Treatment dates ______________
Q# ___ Diagnosis __________________________ Diagnosis date _____________________ Treatment dates ______________
List all prescription medications prescribed over the past 12 months:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Producer Name: ____________________________ Phone: __________________________ Fax: ______________________
HOME OFFICE USE ONLY:
Preliminary Opinion: ______________________________________________________________________________________
Underwriter: _________________________________________________________________ Date: _____________________
Long-term care insurance is underwritten by John Hancock Life Insurance Company (U.S.A.), Boston, MA 02117 (not licensed in New York)
and in New York by John Hancock Life & Health Insurance Company, Boston, MA 02117.
Long-Term Care Insurance
LTC-1028 2/10
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