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Long Term Care Evaluation Form

Please fill out the form below to the best of your knowledge. Upon Submission, an Arizona Insurance Specialist Agent will review your application and be in touch with you within 48 hours.

Your Information


Spouse Information

Fields are optional.

Do you, your spouse, or any dependent
children reside outside of Arizona?

Do you use any mechanical advices such as: a wheelchair,
walker, quad cane, crutches, hospital bed,
dialysis machine, oxygen, or stairlift?

Are you cognitively impaired or do you currently
need or receive help in doing any of the following:
bathing; eating; dressing; toileting;
transferring; or maintaining continence?

Do you have another long term care policy in force?

Are you covered by Medicaid (not Medicare)?