Long-Term Care Insurance Pre-Screening Form For Agent Use Only

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Requests received during normal business hours, Monday - Friday 9a.m. to 3p.m. Eastern Time, will be responded to within 2 hours of MetLife underwriters receiving this e-mail.

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* Required Fields
Submitting agent/representative information

First Name
Last Name
Phone
Email*	>> Invalid Email address
Please enter information about the prospect in the boxes below to receive a pre-screening response from the Long-Term Care Insurance group.

Gender*	>> Required

Age*	>> Required

Height (e.g. 5'10")

Weight If not known, please state whether you think the prospect appears to have an average build.	Yes No

Tobacco Use If yes, enter date of last use. (MM/DD/YYYY)	Yes No

Medical Conditions/concerns*	>> Required

Medication(s) Taken* If yes, please list Rx and reason prescribed.	Yes No>> Required

Does the prospect have any activity limits or use any mechanical equipment?* If yes, please explain and include equipment used and reason for use, e.g. cane, walker, etc.	Yes No>> Required

Memory Loss/Forgetfulness* Limitations: If yes, explain:	Yes No>> Required

Please review the conditions below and check any the prospect may have discussed with you. Provide additional details, if known, by completing the questions associated with the condition(s) you have checked.

Diabetes
1. How long has the prospect had diabetes?
2. What is the prospect's blood sugar and A1C?
3. Does the prospect have any diabetes-related complications? Eye problems directly related to the diabetes Kidney problems Circulatory conditions Numbness and tingling of the extremities Non-healing wounds or skin ulcers	Yes No Yes No Yes No Yes No Yes No

Cancer
1. What type of cancer did/does the prospect have?
2. What stage was/is the cancer in?
3. What was the last date of treatment or surgery?
4. Did the cancer spread to the lymph nodes or other areas of the body?
5. If prostate cancer, what is the prospect's current PSA?

Osteoporosis
1. Does the prospect take medication(s) for his/her osteoporosis? Please list medication(s).
2. Has the prospect's doctor done any bone density studies? What was the result of these studies?
3. Please provide T-score, if known.
4. Have they had any fractures in the last two years?

Arthritis
1. What type of arthritis does the prospect have?
2. What joints are affected?
3. Has the prospect had any joint replacements? Which joints and when?
4. Does the prospect have any limits in activity as a result of his/her arthritis?
5. How far can the prospect walk without resting?
6. Does the prospect have any difficulty with stairs?

Hypertension
1. Is the prospect's hypertension controlled and stable?
2. How many medications is the prospect taking for his/her hypertension? Please list medication if not already identified.

Heart Disease
1. What type of heart disease does the prospect have?
2. If atrial fibrillation, has the prospect had a recent episode? When?
3. Has the prospect had heart surgery? When? What type?
4. Does the heart disease limit the prospect in any way?

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