A long term care insurance questionnaire is helpful to those prospective or existing policy holders who want to adopt an insurance policy for long term purposes which involves knowing their assets and liabilities and their likely distribution among the dependents in the long term.

Sample Long term care insurance Questionnaire:

First Name of the Applicant: _______________________________

Last Name of the Applicant: _______________________________

Name of the spouse (if applicable): __________________________

Home Address: ________________________________________

Office Address: _________________________________________

Employee position or Designation: _________________________

Company working for: ______________________

Phone Number: ____________________________

Email address: _____________________________

DOB: _____________ Gender: ________ Marital Status: ___________

Family profile

No. of children: __________

Children1 name: _________ DOB: _________ Occupation: __________ Marital status: ____

Children1 name: _________ DOB: _________ Occupation: __________ Marital status: ____

Q1. Please mention the total amount of assets possessed by you in each of the following categories

a)   Cash, Bank accounts, Money market funds:    ______________________

b)   Bonds:                                               ______________________

c)   Stocks and Mutual Funds:                     ______________________

d)   Residence:                                 ______________________

e)   Real estate investment:                        _________________

f)    Life insurance policies:                 ________________

g)   Automobiles:                                      ___________________

h)   Collections:                                 ______________________

i)     Others:                                              ____________________

Q2: Please mention the total amount of liabilities under each of the following headings

a)   Creditor:                                    ______________________

b)   Debt:                                         ______________________

c)   Assets encumbered:                            ___________________

Q3. Mention the monthly income of you (and your spouse if applicable)


Q4. Have you adopted any Long Term Care insurance?

a)   Yes

b)   No

Q5: If the answer to the above question is ‘yes’, please mention the following details

Premium: __________No. of years: ______________Coverage: ________

Q6. How do you want your assets to be distributed among your beneficiaries?


Signature: ________________________

Date: ____________________________