N.P. Morith - Long Term Care Planning & Insurance Brokerage

Health History for Long Term Care Insurance

This is NOT an application for insurance. ALL information provided is considered strictly confidential.


	THE IMPORTANCE OF HAVING A DETAILED HEALTH HISTORY
	Insurance companies can differ dramatically from one another when it comes to underwriting long term care insurance. One company might give a standard rate to someone with controlled hypertension, while the next might give that same person a "preferred" rate. One carrier might not even consider insuring someone with controlled insulin-dependent diabetes (Type II). And the next might have no problem giving that individual a standard rate. It is best to deal with these matters in the very beginning so that the company chosen is the appropriate one and the premium quoted is accurate. Without the information we request below, we might just as well "make up" a number for your premium.

	THIS IS A SECURE SITE. Transmission of this health information is protected by Thawte.
	However, you may elect instead to print out this form for manual completion and mail it to us. See our contact information below. If you have questions, please feel free to contact us.
		NP Morith, inc. 13 Roszel Road, C-226 Princeton, NJ 08540 Phone: 800-793-4422 or 609-452-1571 Fax: 609-452-1213

Your Information

	* = Required field

	*First Name:	MI:
	*Last Name:

	*Address:

	*City:
	*State:
	*Zip:

	*E-mail Address:
	*Phone:


1.	*Birth Date: (mm/dd/yyyy)		*Height:		*Weight:

2.	*Tobacco use, current: No Yes - Amount:

(If former tobacco user, provide date of last use: ) (mm/dd/yyyy)

* Married Life partner Companion

*Is spouse/partner/companion applying? Yes No

Single/Widowed/Divorced

4.	*List ALL current prescription medications, dosages, reasons for taking, dates started, dates ended:
	None:

Medication	Dosage	Reason/Diagnosis	Dates

5.	*List EVERY significant health event of last 10 years (e.g., knee replacements, cancers, by-pass operations, TIAs, heart attacks, strokes, arrhythmia's, atrial fibs, fractures, memory loss, etc.)
	None:

Description/Diagnosis	Date of Occurrence	Treatment/Therapy	Date Ended

*Have you ever had long-term care insurance declined or rated? No Yes

*Reason:

Which Insurance Carrier?

Submission Choices:


	Submit Information:


	Submit my Info and let me enter spouse/companion information:

You may also choose to print this form and mail or fax to:

NP Morith, inc.
13 Roszel Road, C-226
Princeton, NJ 08540

Phone: 800-793-4422 or 609-452-1571
Fax: 609-452-1213

NOTICE OF INSURANCE INFORMATION PRACTICES

We at NP Morith, Inc. value our customers' trust and are committed to the responsible use and protection of the information you entrust to us.

We may collect nonpublic personal information about you from personal telephone interviews or from our Health Screening Guidelines form. We may collect information you voluntarily give or send us in the form of copies of medical records or applications for insurance. This information may include your personal health history, doctors' records, records of your prescription medications, family health history and financial information about your income and asset levels, as well as your Social Security number.

PLEASE NOTE: We do not share nonpublic personal information about you for marketing purposes. The health information is used only for helping you choose an appropriate insurance company for underwriting purposes, or helping you make application to an insurance carrier, or administering a claim, or other insurance functions that you may wish us to perform on your behalf.

We restrict access to nonpublic personal information about you to those employees or service providers who need to know the information to provide products or services to you. Nonpublic personal information is stored in a physically secure environment and computer records are kept in password-protected databases with network servers in a physically and environmentally secure location.

N.P. Morith Inc.