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:  
 
Care Home (if known):
Address of Care Home:
Attorney Name (dealing with Care Fees Annuity)
Attorney Address
Attorney Telephone
 
Deferred period:
Frequency benefits are payable (payments are made in advance): Every four weeks Monthly
Escalation month (unless indicated by you, increases will be applied on the anniversary of the policy):
Capital Protection (0-75%):
Capital Protection Plus (0% to limit available on request)
 
 
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





Subarachnoid haemorrhage
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
If yes Current symptoms? Diagnosed over 5 years ago?
Surgical intervention No Yes , once Yes, more than once
Congestive cardiac (heart) failure
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
If yes Current symptoms? Diagnosed over 5 years ago?
Surgical intervention No Yes , once Yes, more than once
Ischaemic heart disease/ Angina
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
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
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
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: