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    Group Long Term Care Quote
    Group Long Term Care Insurance Quote

    Contact Information
    Group Name:
    Telephone:
    Group Contact:
    Fax:
    Group Address:
    E-Mail Address:
    City, State & Zip:
    # of employess to be insured:
    Type of Business:
    How long in business:
    Do you currently offer long-term care insurance to employees?
    Yes   No
    Want long-term care insurance coverage for:
    Give a complete description of any type of hazardous/dangerous duties performed by your employees:
    Current Group LTC Insurance Information
    Carrier (Company) Name (not agency):
    Policy Expiration Date:
    Premium Amt:
    $
    Years Insured:
    Please give a brief description of your
    current Group LTC plan:
    Coverage Options
    Type of Coverage:
    New Coverage
    Additional Coverage
    Replacement
    Waiting Period:
    Daily Benefit Amount:
    Benefit Period:
    Inflation Protection:
    Do you want your policy to include
    home-health care coverage?
    Yes   No
    Employee Information
    (If More Than 10 Employees, place call us to receive a large group census form or use the additional comments box below to add remaining employees.)
    Please list all employees you wish to cover:
    Employee #
    Employee Name
    Birth Date (mm/dd/yy)
    Gender
    Salary
    Select Coverage
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    Additional Comments
    Please give any additional comments or questions

    No coverage of any kind is bound or implied by submitting information via this online form

    • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
    • We will not distribute information to other parties other than for insurance underwriting purposes.
    • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.


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