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    Form: ltc Quote
    Long Term Care Insurance Quote

    Contact Information
    First Name:
    Last Name:
    Daytime Telephone:
    Evening Telephone:
    About You
    Your Birth Date
    Your Gender
    Male Female
    Your Height
    Feet plus inches
    (example 5'6")
    Your Weight
    Are You Married?
    Yes No
    Spouse's Birth Date
    Please Complete For Self/Spouse
    Do you smoke?
    Yes No
    Yes No
    Are you diabetic?
    Yes No
    Yes No
    Are you insulin dependent?
    Yes No
    Yes No
    Do you use a cane?
    Yes No
    Yes No
    Do you use a walker?
    Yes No
    Yes No
    Do you use a wheel chair?
    Yes No
    Yes No
    Do you use any other equipment?
    Yes No
    Yes No
    If you have required assistance with everyday activities in the past 2 years, please explain
    In the past 5 years have you
      Self Spouse
    been confined to a hospital?
    Yes No
    Yes No
    nursing home?
    Yes No
    Yes No
    had home care?
    Yes No
    Yes No
    had long-term care?
    Yes No
    Yes No
    received rehabilitation?
    Yes No
    Yes No
    Please describe your particular
    health problems
    Prescribed medications
    Do you currently own a
    long-term care policy?
    Yes No
    Yes No
    Long-Term Care Quote Selections
    Benefit period desired
    (Average stay in a nursing facility is about 3 years)
    Daily Benefit - nursing home coverage
    Daily benefit - home & community care
    How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?
    The average cost per month is $5,000 which could be more depending on area of country
    Inflation protection/cost-of living adjustment
    Most needed for younger applicants
    Comments or Questions
    Deliver quote via
    E-Mail Fax Regular Mail Telephone
    No coverage of any kind is bound or implied by submitting information via this online form
    We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

    By completing this form, you are acknowledging your understanding of and agreement with these terms

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