Immediate Needs Annuity Quote An immediate needs quote can cap the total cost of long term care for an elderly relative entering a residential or nursing home. The annuity cost is often four to five times the annual income required.       * Indicates a 'Required field', which must be filled before submitting the form.     My Details   Your details are only used in relation to your pension annuity enquiry. We have assumed you are completing this form on behalf of the applicant, therefore please state your relationship with them (e.g. son, daughter, friend, care home manager etc) and give your name and contact details:        Are you completing form for the applicant?: Yes: No:     * Relationship with applicant:          Timescale considered for changes: Immediately 2 to 3 months 4 to 6 months 7 months or more        How did you find our website: --- Please Select --- Google search other search engine from a friend another website newspaper article magazine article other source       * Name: Mr Mrs Ms Miss Dr Prof Rev Sir Lord Other     * Address 1:        Address 2:     * Town/City:        County/Country (if overseas):     * Postcode:       * Email address:     * Phone number:       * Applicant's Name:     * Applicant's date of birth: day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 month 01 02 03 04 05 06 07 08 09 10 11 12 year 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954     * Applicant's gender: --- Please Select --- male female     Funds for Annuity   Please indicate the expected total annual cost for the residential or nursing home and if you have secured NHS funding or support from the Local Authority to cover some of the costs of care.     * Estimated total annual fees:          Funding from the NHS?: Yes: No:        Funding from the Local Authority?: Yes: No:       * Annuity annual income required:        Or Annuity lump sum available:     Please complete the following if you are currently being provided with care:   Not currently receiving care:   Care Home (with nursing care):   Care Home (no nursing care):   Own Home:   Other:          Duration of care to date (if applicable):     Disease and Impairments   Please indicate if the applicant suffers from any of the following diseases or impairments and the severity (ADL means Activities of Daily Living):   1. Cancer 2. Stroke   Date diagnosed:     Date diagnosed:     Not applicable     Not applicable     Cured in short term     Minor disability, some ADLs     Receiving treatment     Major disability, total care     Receiving palliative care       3. Diabetes 4. Heart Failure   Date diagnosed:     Date diagnosed:     Not applicable     Not applicable     Non insulin dependent     Controlled with medication     Insulin dependent     Medication but still symptoms     5. Pneumonia 6. Respiratory Disease   Date diagnosed:     Date diagnosed:     Not applicable     Not applicable     1-2 episodes in the last year     Intermittent oxygen insufflation     3+ episodes in the last year     Daily oxygen insufflation     7. Contracture 8. Pressure Ulcers   Date diagnosed:     Date diagnosed:     Not applicable     Not applicable     Partial stiffening of 1+ joints     Controlled with medication     Severe stiffening of 1+ joints     Medication but still symptoms     9. Nutrition     Date diagnosed:       Not applicable       Requires assistance       Artificial nasogastic / PEG feeding         Please indicate if one or more of the following disabling diseases have been diagnosed:       No Yes   Date Diagnosed     10. Dementure       11. Multiple Sclerosis       12. Motor Neurone Disease       13. Parkinson's Disease       Activities of Daily Living   Please indicate if you or your relative has difficulty with any of the following Activities of Daily Living:     1. Communication     Good/fluent, easy to understand     Moderate, sometimes difficult to understand but makes needs known     Poor or unintelligible cannot make needs known       2. Orientation     Alert or lucid and responsive     Sometimes forgetful, vague with lucid periods     Confused with no lucid periods       3. Mobility     a) Toilet use:-     Independent (clothing, wiping)     Needs some help with clothing, getting on/off toilet but can do some alone     Requires full assistance and bowel care, changing clothes and linen daily     b) Transfer (bed to chair and back):-     Independent     Minor help, can sit unaided but needs some limited assistance     Major help, no sitting balance and needs one or two people to assist     c) Dressing:-     Independent ( eg buttons, zips, laces)     Needs some assistance with fasteners, getting in and out of the bath     Requires full assistance     d) Stairs:-     Can walk up and down stairs unaided     Requires some assistance     Cannot walk up or down stairs       4. Continence     Continent     Occasional accident     Incontinent and needs indwelling catheter and protective clothing     Additional comments you would like to make regarding this form:   Sending the form