Care Fees Annuity Quotations

Completing the details below will enable us to provide you with an indicative annuity quote, which will be subject to further medical underwriting. It is important to answer all questions fully so that an accurate assessment can be made with regard to the cost of funding the benefits required. If an application is then submitted you will be asked to sign a declaration in accordance with the Access to Medical Records Act (AMRA). This data is provided in the strictest confidence and its use is fully covered under the Data Protection Act 1998. If you require assistance when completing the form, please feel free to call us on 01483 825609.

Care Fees Annuity Details
Nursing Fees (£p.a.) or lump sum available:	Benefit Required Lump sum available
Target amount per annum/ lump sum available:
Resident's Name:
Care Home (if known):
Address of Care Home:
Attorney Name (dealing with Care Fees Annuity)
Attorney Address
Attorney Telephone
Guarantee Period:	None 5 years 10years
Deferred period:	None 1 year 2 years 3 years 4 years 5 years
Frequency benefits are payable (payments are made in advance):	Every four weeks Monthly
Escalation :	Level Retail Prices Index 1% 2% 3% 4% 5% 6% 7% 8%
Escalation month (unless indicated by you, increases will be applied on the anniversary of the policy):	On the anniversary January February March April May June July August September October November December
Capital Protection (0-75%):
Capital Protection Plus (0% to limit available on request)
E-mail address:
Gender :	Male Female
Date of Birth:
Date of admission (if known):
Marital Status:	Bachelor/ Spinster Married Divorced Separated Widowed
If bereaved, how long for?	Within last 6 months Within last 6-12 months More than one year ago
Does the home have regular activities?	Yes No Don't know
Will the resident receive regular visits?	Yes No Don't know
Where was the client admitted from?	Home Hospital Residential Home Nursing home
Where is the client now?	Home Residential Home Nursing Home
How long has the client been there?	Less than 6 months More than 6 months
Nationality?
Cancer	No Only tiny tumour growth (carcinoma in-situ) Only local tumour growth Tumour invaded adjacent lymph nodes Tumour invaded distant lymph nodes Tumour spread to distant organs (distant metastases)
Subarachnoid haemorrhage	No Yes
If yes	Recent recurrence? First event over 5 years ago?
Transient Ischaemic Attack (minor stroke)	No Yes
If yes	Recent recurrence? First event over 5 years ago?
Cerebrovascular Accident (major stroke)	No Yes
If yes	Recent recurrence? First event over 5 years ago?
Diabetes	No Yes
If yes	Diagnosed over 5 years ago? Diabetic complications
Atrial fibrillation	No Yes
If yes	Current symptoms? Diagnosed over 5 years ago?
Surgical intervention	No Yes , once Yes, more than once
Congestive cardiac (heart) failure	No Yes
If yes	Current symptoms? Diagnosed over 5 years ago?
Surgical intervention	No Yes , once Yes, more than once
Heart attack	No Yes
If yes	Current symptoms? Diagnosed over 5 years ago?
Surgical intervention	No Yes , once Yes, more than once
Peripheral vascular disease	No Yes
If yes	Current symptoms? Diagnosed over 5 years ago?
Surgical intervention	No Yes , once Yes, more than once
Ischaemic heart disease/ Angina	No Yes
If yes	Current symptoms? Diagnosed over 5 years ago?
Surgical intervention	No Yes , once Yes, more than once
High blood pressure/ hypertension	No Yes
If yes	Current symptoms? Diagnosed over 5 years ago?
Surgical intervention	No Yes , once Yes, more than once
Asthma	No Yes (if ongoing problems with symptoms in the last 12 months).
Emphysema/ COPD	No Yes (if ongoing problems with symptoms in the last 12 months).
Pneumonia	No Yes (if ongoing problems with symptoms in the last 12 months).
Recurrent chest infections	No Yes (if ongoing problems with symptoms in the last 12 months).
Multiple Sclerosis	No Yes
Parkinson's Disease	No Yes
Dementia	No Yes
Depression	No Yes (symptoms in the last 24 months)
Fractures	No Yes, in last 6 months Yes, 6-12 months ago
Osteoarthitis/ Rheumatoid arthritis	No Yes
Dyspnoea (shortness of breath)	No Yes
Chest pain	No Yes
Recurrent falls (at least 2 in the last 6 months)	No Yes
MMSE score	Not known 25-30 17-24 8-16 7 or below
Orientation in place?	No Yes
Orientation in time?	No Yes
Memory	Good Fair Poor
Change in condition over time	Stable Deteriorating Rapidly deteriorating
Leg Oedema (swelling)	No Yes
Bowels	Incontinent Occasional incontinence Continent
Bladder	Incontinent or catheterised and unable to manage Occasional incontinence Continent
Grooming	Needs help Independent (with face/ hair/ teeth/ shaving)
Toilet use	Dependent Needs some help, but can do some things Independent (on, off, dressing and wiping)
Feeding	Unable Needs help (with cutting, spreading butter, etc) Independent
Transfer	Immobile Major help (1-2 people, physical) Minor help (verbal or physical) Independent
Mobility	Immobile Wheelchair dependent Walks with the aid of 1 person (verbal or physical) Independent (but may use any aid- ie stick)
Dressing	Dependent Needs help (verbal, physical or carry aid) Independent
Stairs	Unable Needs help (verbal, physical or carry down) Independent up and down
Bathing	Dependent Independent
Height	ft inches or cms:
Weight	st lbs or kgs:
Pressure sores	No, not within the last 6 months Within the last 6 months Current
Blood pressure	Reading at or below 150/90 Reading above 150/90
PEG feeding	No Yes
Number of prescribed medicines
Regular oxygen use	No Yes
Please provide any further relevant details which you feel could assist underwriting in assessing the annuitant's health: