1. Long Term Care Needs Evaluation Worksheet
This information is strictly confidential, and is used solely to help determine a suitable Long Term Care Plan
Primary Applicant
Name
Age/Birth Date
Height/Weight
Smoker/Tobacco Use Yes / No
Spouse/Domestic Partner
Name
Age & Birth Date
Height & Weight
Smoker/Tobacco use Yes / No
Primary Applicant
Address
City, State, Zip
Email Address
Phone Numbers Day__________Evening____________Mobile________________
Spouse/Domestic Partner
Email Address
Phone Numbers Day__________Evening______________Mobile_______________
Are you currently receiving Medical, Social Security Disability, or Workers Compensation? If yes, what type?
Primary Applicant
Yes / No
Spouse/Domestic Partner
Yes / No
1. Long Term Care Background…Any prior LTC experience/knowledge with parents, family
members or friends? If so, how was care paid for, and how did it affect you?
2. Long Term Care Planning Issues
What would you expect Long Term Care Insurance to do for you? Check all that apply.
Provide financial means to pay for care, rather than using assets and Income
(Long Term Care Purchasing Power)
Preserving choices and options on where to receive care/Preserving Legacy & Dignity
Protecting family from devastating emotional and financial consequences
Avoiding medical issues to family members who provide your care
Produce funds to control estate planning issues and to protect assets
Maintaining my independence and standard of living
Any plans to move to another state? Which one?_________________-

2. 3. Prescription Medications and Purpose
Primary Applicant Spouse/Domestic Partner
Any major illnesses or hospitalization in last 5 years?
Primary Applicant Spouse/Domestic Partner
Any use of mobility aids (walker, wheel chair, power chair, cane) and years of use?
Primary Insured Spouse/Domestic Partner
Activities
Primary Applicant Spouse/Domestic Partner
Employed Yes No Employed Yes No
Exercise Yes No Exercise Yes No
Volunteer Yes No Volunteer Yes No
4. Retirement/Estate Planning Goals to provide for:
Self/Spouse
Children
Charities
5. Any Special Needs Family Members? (Disabilities) What are those needs?
Yes No Self
Yes No Spouse/Partner
Yes No Children
Yes No Parents/Siblings
6. Do you own your primary residence? Yes No Is there any other property involved in
estate/retirement Planning?
Primary Applicant Spouse/Domestic Partner
Family Property / Value: $ Value: $
Farm / Value: $ Value: $
Rental Property / Value: $ Value: $
Commercial / Value: $ Value: $

3. 7. Financial Considerations
How are you currently prepared to pay for Long Term Care?
Income, Assets, Retirement Portfolio
Medical (Do you qualify?)
Long Term Care Policy
Primary Applicant Spouse/Partner
Asset Protection Over Under Over Under
If asset protection is a concern/priority
Are assets you wish to protect over or
under $750,000?
If under, are total assets you wish to
protect over $250,000?
If under $250,000 how much of that do
you wish to protect?
Monthly Income Primary Applicant Spouse/Domestic Partner
Employment/Business $ $
Pension/Social Security $ $
Retirement Portfolio $ $
8. For Federal Tax purposes, are you a business owner? Yes / No
If yes, what type of business? Primary Insured Spouse/Domestic Partner
Sole Proprietor
S Corp
LLC / LLP
C Corp
9. Is there anyone in your everyday life that you feel would benefit from a Long Term
Plan of Care? If so, may I have their name and phone number?
Name Phone Number

4. 2008 Nursing Home Costs in California 2008 Nursing Home Costs in California
Daily and Annual Average Rates for a Daily and Annual Average Rates for a
Private Room Semi-Private Room
$274 / $100,010 $189 / $68,985
2008 Assisted Living Costs in Calif. 2008 Home Health Care Costs in Calif.
Monthly and Annual Average Rates Home Health Aide/Certified Nursing
$3,663 / $43,956 Assistant and LPN Hourly Rates
HHA or CNA Hourly Rate $21
LPN Hourly Rate $51
These figures are part of a 2008 Cost of Care Study performed by Prudential Insurance Co.