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Long Term Care

Questionnaire

Please complete your HIPAA Compliant Long Term Care Questionnaire!  After you submit the questionnaire you will be redirected to a webpage to schedule an appointment if desired.

Long Term Care Insurance is medically underwritten. This means that your health history determines if you are eligible to purchase coverage. We would like to ask some health question first in order to determine insurability. Kindly answer the questions below and provide as much detail as possible. After you submit the questionnaire, you will be redirected to a webpage to schedule an appointment.
Would you like to shop coverage for a spouse/partner as well?(Required)

YOUR Medical Info

Tobacco Use in the last 12 months?(Required)
Family History of Dementia or Alzheimer's(Required)
Congestive Heart Failure(Required)
Heart Attack, Stroke or TIA(Required)
Internal Cancer or Melanoma(Required)
Atrial Fibrillation(Required)
Diabetes(Required)
Arthritis , History of injections, Joint pain or Joint replacement(Required)
Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)(Required)
Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis(Required)
Any physical, occupational or speech therapy- in past 6 months, current, or recommended?(Required)
Any scheduled or recommended surgery or treatment in next 12 months?(Required)

Contact Us

Our Address

100 Campbell Blvd.
Suite 100
Exton, PA 19341

Contact Us

Info@HTA-insurance.com
P: 610.430.6650
F: 610.430.6652

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