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For a free Long Term Care Planning Kit and more information, visit the 
U. S. Department of Health and Human Services' website,
www.longtermcare.gov

For additional information on Long Term Care options from Alan Benoy Insurance Services, complete the form below.

 

First Name:
Last Name:
Evening Phone:
Day Time Phone:
Address:
City:
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Birth Date:  

Height:
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(pounds)
Currently enrolled in:
Brief Health Survey
How do you classify your health?
Diabetic? Yes No         Insulin dependent? Yes No
Do you need assistance with everyday tasks?   Yes No
Do you take any medication? Yes No
Please list any medications, health issues, concerns, or comments here.
 

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