United Underwriters, Inc.
Exeter, NH - Avon, CT - Rockville, MD
PO Box 1103 Exeter, NH 03833

Long Term Care Pre-Qualification Questionnaire
Name: Date of Birth:
Height: Weight:
Are you a smoker? Yes No  
1. Are you currently taking any medication? Yes No
 

If yes, please list the name of the medication, the dosage (if you know), and the conditionyour are taking it for.
2. Have you been hospitalized within the last 5 years? Yes No
 

If yes, please list the dates and conditions you were hospitalized for.
3. Have you seen a specialist within the last 5 years? Yes No
  If yes, please list the dates and condition you saw a specialist for.
4. Have you ever been diagnosed or treated for any of the following?
 

Cancer Alzheimer's Dementia Multiple Strokes Multiple Sclerosis

Diabetes 100+ units of insulin Incontinence Muscular Dystrophy Emphysema & Current Smoker
Agent Name: Agent Phone: Date:

Additional Comments: