Reliable Financial Group

CPS-Reliable Financial Group
Experts in Business, Estate and Personal Life Planning
A CPS Insurance Services, Inc. Affiliated Office

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CLIENT INFORMATION AND REQUALIFICATION DETAILS

The underwriting of Long Term Care Insurance differs from hat of other products (such as life insurance) in that one must consider many unique factors, for which another type of insurance might not seem important. Our mission is to provide the highest quality service to you and your clients. Good health pre-qualifying allows us to help you place the right policy for your clients quickly and accurately.

AGENT/BROKER INFORMATION
*All Agent information is required.

*Name:	*Phone	(xxx-xxx-xxxx)
*Street Address:	*Fax Number:	(xxx-xxx-xxxx)
*Suite or Unit #	*Email Address:
*City:
*State:
*Zip:

CLIENT #1 NAME:

DOB: State: Gender: Male Female

Height: Weight: Married: Yes No

Have you used tobacco products in the last 12 months?

Yes No

Within the last 5 years, have you received medical advice, diagnosis, treatment, or consulted with
a medical professional for:

Circulatory disorders (includes high blood pressure)

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

Have you had any surgery recommended or anticipated?

Yes No

Are you currently receiving physical therapy?

Yes No

Do you currently use any assistive or mechanical devices?

Yes No

Have you ever received home health care or been confined to a
nursing home or rehabilitation facility?

Yes No

Do you require human assistance or supervision in performing any
of your activities of daily living?

Yes No

Have you had a complete physical exam within the past 18 months?

Yes No

List any prescription medication taken and dosage:

Please give details to questions 2 through 7, if Yes is checked:

? #	Diagnosis	Diagnosis Date	Treatment

Relationship between Client 1 and Client 2:

State the Illustration is for:

CLIENT #2 NAME: (only if Joint)

DOB: State: Gender: Male Female Height: Weight:

Have you used tobacco products in the last 12 months?

Yes No

Within the last 5 years, have you received medical advice, diagnosis, treatment, or consulted with
a medical professional for:

Circulatory disorders (includes high blood pressure)

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

Have you had any surgery recommended or anticipated?

Yes No

Are you currently receiving physical therapy?

Yes No

Do you currently use any assistive or mechanical devices?

Yes No

Have you ever received home health care or been confined to a
nursing home or rehabilitation facility?

Yes No

Do you require human assistance or supervision in performing any
of your activities of daily living?

Yes No

Have you had a complete physical exam within the past 18 months?

Yes No

List any prescription medication taken and dosage:

Please give details to questions 2 through 7, if Yes is checked:

? #	Diagnosis	Diagnosis Date	Treatment

Relationship between Client 1 and Client 2:

State the Illustration is for:

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Web site Created: September 2002