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Request Long Term Care Quotation

 
Long Term Care Insurance Quotation Request Form
(Remember that Long Term Care Insurance is a very complicated type of insurance.  You should  consult with a professional before the purchase of such a policy.  This form will enable you to get a preliminary quotation prior to a consultation.   Remember that this in no way constitutes a policy or approval of such coverage.  A full application would have to be underwritten and approved before delivery of a policy!


(Please fill in all the information below and press submit. A quotation will be sent to you shortly)

 

Name
Spouse Name(Leave Blank if No Spouse Coverage Desired)
Street 
City
State
Zip Code
Email Address
Telephone
Date of Birth
Date of Birth Spouse
Have you used tobacco products in the past year?
         You Spouse
Are you currently taking any prescription medications? (if yes, please explain in space below)
          You Spouse
Would you be interested in a combination policy that provides benefits for both Nursing Home and Home Health Care?

                           

Daily Benefit Amounts depend on your place of residence in addition to facility charges.  It is recommended that you contact local facilities in order to find out current daily charges.  Please indicate a desired Daily Benefit amount for quoting purposes.  It is recommended that you apply for at least $150 per day in benefit:

                           

Long Term Care/Home Health Care is available in several benefit periods.   Please choose a benefit period for the initial quotation, however, before purchasing, please seek professional advice!
                                                     
How long do you feel as though you could pay the cost of a Nursing Home or a Home Health requirement? (Remember, the longer you can self-insure, the lower the premium will be!)

                                                      

The compound inflation rider is an excellent way to help keep pace with inflationary pressures on Nursing Home/Home Health costs.  A 5% Compounded Rider is available in most cases.  Would you like us to quote this Rider for you?

                            

Use the space below to tell us any information that may be helpful in quoting this insurance for you!  (This should include prescriptions you may be taking and any other information that you think would be important in underwriting an application for this insurance:

 

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