Long Term Care Insurance Quote

Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information
*First Name
*Last Name
Street Address
City/St/Zip
*Phone Number
Alternate Number
*Email Address
Birthdate
Gender  Male Female
Height (example 5'8")
Weight (lbs)
Marital Status
If married, Spouse's Birth Date:
Height (Spouse):
Weight (Spouse):

Additional Information

Individual 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
Please explain if you have required assistance with everyday activities in the past 2 years:

In the past 5 years have you: (check all that apply)

Individual Spouse
been confined to a hospital?  Yes  Yes
been confined to a nursing home?  Yes  Yes
had home care?  Yes  Yes
had long-term care?  Yes  Yes
received rehabilitation?  Yes  Yes
Please describe your particular health problems:
Prescribed Medications:
Do you currently own a long-term care policy?  Yes No  Yes No
Best Time To Contact You
Please let us know the best time to call and discuss your quote  Morning Afternoon Evening Anytime Or Specify Other:
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