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Ivy Tech Community College
Long Term Care Insurance
Request for Proposal
Information shared in this request for proposal will be used exclusively for the purpose of
evaluating long term care information. It is strictly confidential and will not be shared with your
employer or anyone not directly related to this long term care program. If you have any questions
do not hesitate to call us at (317) 469-9600 or toll free (866) 686-7589.
Sending your request by mail:
Frank A. Leyes & Associates
3500 DePauw Boulevard
Pyramid II ∙ 4th Floor ∙ Ste. 2042
Indianapolis, Indiana 46268
Sending your request by email:
[email protected]
Sending your request by fax:
(317) 469-9601
Applicant One Name
Applicant Two Name
Are you an Ivy Tech employee?
Yes
No
Are you an Ivy Tech employee?
Yes
No
Home Address
Home Address
Home
Telephone
Office
Telephone
Date Of Birth
Home Email
Home Telephone
Home Email
Office Email
Office
Telephone
Date Of Birth
Office Email
Height
Weight
Are you married?
Yes
Height
Do you reside with
Applicant One?
Yes
No
No
Weight
Relationship To
Applicant One
Smoking
Smoker
Non-smoker
Insurability Questions
Smoker
Non-smoker
Have you had, do you currently have, have you
ever been medically diagnosed as having or have
you been treated for:
 Stroke (CVA)
 Muscular Dystrophy
 Multiple Transient
 Multiple Sclerosis
Ischemic Attacks
 Organ Transplant
(TIA’s)
 Parkinson’s Disease
 TIA within 5 years
 Cancer (except basal
 Alzheimer’s Disease
cell caner) with
 Dementia
metastasis; or cancer
 Mental Retardation
treated in any
 Schizophrenia
manner in the past
 Amyotrohic Lateral
24 months
Sclerosis (Lou
 Diabetes with
Gehrig’s disease)
amputation or
complications within
the past 5 years
affecting the kidney
Yes
No
Have you had, do you currently have, have you
ever been medically diagnosed as having or have
you been treated for:
 Stroke (CVA)
 Muscular Dystrophy
 Multiple Transient
 Multiple Sclerosis
Ischemic Attacks
 Organ Transplant
(TIA’s)
 Parkinson’s Disease
 TIA within 5 years
 Cancer (except basal
 Alzheimer’s Disease
cell caner) with
 Dementia
metastasis; or cancer
 Mental Retardation
treated in any
 Schizophrenia
manner in the past
 Amyotrohic Lateral
24 months
Sclerosis (Lou
 Diabetes with
Gehrig’s disease)
amputation or
complications within
the past 5 years
affecting the kidney
Yes
No
Have you ever been treated for or medically
diagnosed as having Acquired Immune Deficiency
Syndrome (AIDS), AIDS Related Complex (ARC),
any AIDS related condition(s) or tested positive for
antibodies to the AIDS virus?
Yes
No
Have you ever been treated for or medically
diagnosed as having Acquired Immune Deficiency
Syndrome (AIDS), AIDS Related Complex (ARC),
any AIDS related condition(s) or tested positive for
antibodies to the AIDS virus?
Yes
No
Do you currently reside in, have you been advised
to enter, or are you planning to enter a nursing
home, assisted living facility, or other residential
care facility; or are you currently receiving home
health care services or attending adult day care?
Yes
No
Do you currently reside in, have you been advised
to enter, or are you planning to enter a nursing
home, assisted living facility, or other residential
care facility; or are you currently receiving home
health care services or attending adult day care?
Yes
No
Do you require human help or supervision for any
of the following: bathing; dressing; eating;
walking; toileting; transferring from bed or chair;
controlling bowel or bladder?
Yes
No
Do you require human help or supervision for any
of the following: bathing; dressing; eating;
walking; toileting; transferring from bed or chair;
controlling bowel or bladder?
Yes
No
Do you currently use any of the following: dialysis;
oxygen; wheelchair; walker; quad cane; crutches?
Yes
No
Do you currently use any of the following: dialysis;
oxygen; wheelchair; walker; quad cane; crutches?
Yes
No
Health History
Please describe any other significant health history
or medication (name, dosage, and reason) taken
during the last five (5) years.
Please describe any other significant health history
or medication (name, dosage, and reason) taken
during the last five (5) years.