Want to learn more?
Phone Phone: 843.556.7400
frank@frankurban.net

How to Prequalify?

Do you qualify for the Improved Pension Benefit and/or one of the two add-ons, “Housebound” or “Aid and Attendance”?

To prequalify, please fill out the form below and then click the submit button. Please indicate if you are currently working with one of our analysts. All information provided is confidential and will not be used for any other purpose.

We receive many inquiries every day, and therefore, may take us a few days to respond to your form. You may also call 843.556.7400 to leave a message or e-mail frank@frankurban.net




INQUIRER INFORMATION:

* Mandatory fields

* First Name: * Last Name:    
Address:
City: * Contact Phone Number:    
State/Region: * E-mail:    
Zip: * E-mail Confirmation:    
For whom are you requesting this information?
Other? Please specify:
Are you currently living in a nursing home or assisted living center?   
How were you referred to us, or list the facility where you are currently located? 



TELL US ABOUT THIS PERSON:

First Name: Age:                            Marital Status:
Last Name: Spouse's Name:             Age:
Current Address:
City/State/Zip:         
Current Resident Type:        Do you own or rent:  
Monthly Payment: Property Value:  
Do you plan on living in assisted living soon?
If so, what do you plan on spending per month?





WARTIME SERVICE QUESTIONNAIRE:

VETERAN SURVIVING SPOUSE OF A VETERAN
Is the veteran age 65 or older or permanently disabled? Is the un-remarried surviving spouse the last spouse of the veteran at the time of his death?
Did theveteran serve at least 90 days in active service, with at least one day during a wartime period? Did the deceased veteran serve at least 90 days in active service, with at least one day during a wartime period?
Did the veteran receive an honorable or general discharge? Did the deceased veteran receive an honorable or general discharge?



HEALTH QUESTIONNAIRE:

MEDICAL DIAGNOSIS:
   Alzheimer's   Dementia   Other 
SELECT THE ACTIVITIES OF DAILY LIVING, THIS PERSON REQUIRES ASSISTANCE WITH:
   Dressing   Bathing   Toileting   Transferring   Continence   Meals   Medication Mgmt  



MONTHLY INCOME/EXPENSE QUESTIONNAIRE:

INCOME VETERAN SPOUSE
Social Security $ * $ *
Pensions $ * $ *
Interest Income $ $
VA Retirement or Disability $ $
Other $ $
Total Monthly Income $ * $ *
EXPENSES
Medicare Part-B $ $
Private Medical Insurance/ Medicare Supp. $ $
Senior HMO $ $
Monthly Home Care Costs $ * $ *
Monthly Cost of Facility $ $
Cost of Long Term Care Insurance $ $
Total Monthly Medical Expenses $ $
SAVINGS
Checking, Savings, CDs $ $
Stocks, Bonds, Mutual Funds $ $
IRAs $ $
Other  
$ $
Total Asset/Savings: $ * $ *

Click the submit button to send the form.