The Todd Benefits Group, Inc.

Personal Interest Form

Please provide the following information about yourself and your partner (if applicable). A licensed insurance agent will send you personalized cost and benefit information and an application request form for the Long-Term Care Insurance Plan. Answering the questions on this page will not result in a determination of you eligibility for coverage.

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Organization

Affiliation

Yourself

First Name	M.I.	Last Name

Date of Birth

Your Partner (if applicable)

First Name	M.I.	Last Name

Date of Birth

Address

City	State

	Zip

Home Phone

Work Phone

Email Address

Do you currently own Long-Term Care Insurance?	If yes, what is the name of the insurance company?

Yes No

Have you used tobacco products in the last twelve months?

You:

Yes No

Your Partner:

Yes No

List any medical condition(s) for which you require ongoing medical treatment:

You:	Your Partner:

List any prescription drugs that you are currently taking:

You:	Your Partner: