Long Term Care Insurance Quote – California Services and Compass Services

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	MaleFemale
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?	YesNo		YesNo
Are you Diabetic?	YesNo		YesNo
Are you Insulin Dependent?	YesNo		YesNo
Do you use a cane?	YesNo		YesNo
Do you use a walker?	YesNo		YesNo
Do you use a wheel chair?	YesNo		YesNo
Do you use any other equipment?	YesNo		YesNo
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?	YesNo		YesNo
Best Time To Contact You
Please let us know the best time to call and discuss your quote	MorningAfternoonEveningAnytime	Or Specify Other:

*Please prove you're human by entering the Captcha characters

Quote Request

Additional Information

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