Please complete all sections, then select Submit at the bottom of the final page.

 
 25% of survey complete.
NEXT STEP:  Complete this health questionnaire so we may determine your eligibility to apply.  
 
Estimated 2 to 4 minutes to complete. 
Simply close your browser if you want to stop and not submit your answers.

-   This is NOT an application for insurance.  This information is used to determine your eligibility to apply for a policy.  If you qualify, we will contact you and when you are ready, assist you with submitting an electronic application. 
- Health information is ONLY used to assess your eligibility for insurance.     
-   One questionnaire per person.  You may complete for someone else if familiar with their health history.   
-   Questions? 855-204-1214 
 
This Questionnaire is HIPAA compliant.
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* 1. What coverage amount was of greatest interest to you?

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* 2. State of residence (Product available only in listed states)

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* 3. What is your Date of Birth (MM/DD/YYYY)?    Product available for ages 35-84

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* 4. Within the past 12 months
- have you been diagnosed as having, been prescribed medication for or been treated by a member of the medical profession for Alzheimer's disease, dementia, multiple sclerosis, Parkinson's disease, cancer, heart disease, stroke or kidney failure?
- have you required Home Health Care, Skilled Nursing services, Adult Day Care or had a Nursing Home stay?
- have you required assistance in performing Activities of Daily Living; bathing, continence, dressing, eating, toileting, or transferring.  
- have you required a wheelchair, 4-prong cane, walker, hospital bed or motorized care?
- have you required physical, occupational, or speech therapy?

LTCI Partners was selected by the HCG Secure to help consumers with this important planning.

LTCI Partners, LLC, (LTCI Partners) acts as an agent for select insurance companies to provide insurance under this program. Invitations for application for insurance are made through LTCI Partners. LTCI Partners or its licensed representatives are currently licensed in all 50 states and the District of Columbia. California license number 0D51716. Other license numbers are available upon request. LTCI Partners receives commissions from insurance carriers, which include compensation based on total quantity and quality of insurance coverage.

The insurance policy describes coverages under the policy, exclusions and limitations, what you must do to keep your policy in force, and what would cause your policy to be discontinued. Please contact your licensed agent for more information, costs, and complete details on coverage. Availability of policies, features, and benefits may vary by state.

An insurance agent may contact you. Premiums vary by issue age and health and for some plans may be increased in the future. The insurance is underwritten by the insurance company we help you select. Your application approval is not guaranteed.

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