Best available Long Term Care Quote!
Primary Potential Insuree
Who are you requesting this quote/support for? (Couples - only fill out one request.)
Myself - Female
Myself - Male
Aunt/Uncle Age
Sibling/Child Age
Friend
Other Relation Age
Name:
Date of birth:
(MM/DD/YYYY)
Gender:
Female
Male
Health:
Excellent
Average
Poor
Tobacco:
Yes
No
(has the PRIMARY insuree used a tobacco product in the past five years?)
Any hospitalizations in the past 10 years?
Yes
No
Please list any current medications:
Name of drug
Description
Dosage
Frequency
Address:
City:
State:
ZIP Code:
Contact number:
Email Address:
SPOUSE/LIFE PARTNER of Potential Insuree:
Name:
Date of birth:
(MM/DD/YYYY)
Gender:
Female
Male
Health:
Excellent
Average
Poor
Tobacco:
Yes
No
Additional Information:
For optimal pricing, would you be willing to answer several, brief health questions?:
Yes
No
Is there any reason you would not choose to own Long Term Care Insurance protection within the next 90 days?:
Yes
No
If so, what would this reason be?:
If you already own Long Term Care Insurance coverage, would you like a competitive comparison?:
Yes
No
Please list the names of your current long term insurance carrier or any companies from which you have received quotes.
What is the main reason for seeking coverage now?
What is most important about long term care protection for you?
Prefer to talk to an agent?
Call us anytime at
630-369-0759