Long Term Care Quote

Long Term Care Insurance Quote Request
First Name
Last Name
State
Gender
Phone Number

Area CodePhone Number
Type:
E-mail
Which do you prefer:
Best times to reach you?
Basic information needed to generate a fairly accurate quote:
Note: The average daily cost for Long Term Care in 2011 is close to $250 per day.
Daily Benefit Desired:
Any particular features desired?
If yes, please describe. If no, we will include common riders and features
Date of Birth

MonthDayYear
Height (inches)
Weight (lbs)
Tobacco Use?
If yes, what type of tobacco? How often do you use tobacco? How long have you used tobacco?
Do you have (or have had) any significant medical illnesses, ailments or injuries?
If yes, please briefly describe:
Do you currently take any medications?
If yes, which medications? Dosage? How often? How long have you been taking them?
.
Other helpful information (not required at this point):
Total Existing Coverage:
Description: (When was policy put in place? Benefit period? Elimination period? 100% Home care? Riders included?)
Enter information if known:
Blood Pressure
Total Cholesterol
Total / HDL Ratio
Foreign Travel Planned?
If yes, where? For how long? Is it for business, vacation, other?
Do you have any moving violations?
If yes, what type of violation? When did they occur?
Significant Sports / Activities (rock climbing, piloting, scuba diving, racing, sky diving, etc.)
Family History (parents & siblings cause of death, any severe medical conditions, age, diabetes, etc.)
Additional information (including any information on a spouse or others if a quote desired for them.)
Address:
City
Postal / Zip Code
Alternate Phone Number

Area CodePhone Number
Type:
*Premium indications provided are not firm quotations and are not bindable. Terms, limits, deductibles, conditions and price may change upon receipt, review and acceptance of a completed application and supporting documentation by the company.

A binding quotation will not be issued without the company's full underwriting due dilligence.
Should be Empty:

Long Term Care Insurance Quote Request

Basic information needed to generate a fairly accurate quote:

Other helpful information (not required at this point):