Mrs. Kasmikha Family Financial Security

SAMPLE If family member or other, please specify name and relationship If No, where is the insured currently living? o Nursing home o Assisted Living Facility o Home of family member o Other Name of facility/person Telephone Address: Street City State ZIP Cognitive Impairment Claims Only 1. W hen did you or the insured’s licensed health care practitioner first conclude that the insured, due to a severe cognitive impairment, requires continuous supervision to protect himself or herself from threats to health or safety? / / 2. List the name, relationship, and phone number of the individual (including family members), agency, and/or facility that currently provide(s) this supervision. Name of agency/person Telephone Relationship Date Supervision First Provided / / Description of Assistance Provided and Frequency 3. History of Chronic Illness (continued) 3. List licensed health care practitioners that have treated the insured for this chronic condition within the past 5 years. Name of licensed health care practitioner Address: Street City State ZIP Telephone number Dates of treatment From / / To / / Name of licensed health care practitioner Address: Street City State ZIP Telephone number Dates of treatment From / / To / / Name of licensed health care practitioner Address: Street City State ZIP Telephone number Dates of treatment From / / To / / Name of licensed health care practitioner Address: Street City State ZIP Telephone number Dates of treatment From / / To / / 4. Is the insured currently living at the address listed in section 1 on page 1? o Yes o No If Yes, with whom is the insured living? o Alone o Family Member o Other

Name of agency/person

Telephone

Relationship

Date Supervision First Provided

/

/

Description of Assistance Provided and Frequency

Name of agency/person

Telephone

Relationship

Date Supervision First Provided

/

/

Description of Assistance Provided and Frequency

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COMB 115174-2

Ed. 10/2017