LTC Quote 
Long Term Care Insurance Quote
Contact Information:
1
First Name:
2
Last Name:
3
Daytime Telephone:
4
Evening Telephone:
5
Email:
6
Address:
7
City:
8
State:
9
Zip:
About You:  
10
Your Birth Date
11
Your Gender
Male Female
12
Your Height
Feet plus inches (example 5'6")
13
Your Weight
14
Are You Married?
Yes No    
Spouse's Birth Date
Please Complete For Self/Spouse  
15
   
Self
Spouse
a
Do you smoke?
Yes No
Yes No
b
Are you diabetic?
Yes No
Yes No
c
Are you insulin dependent?
Yes No
Yes No
d
Do you use a cane?
Yes No
Yes No
e
Do you use a walker?
Yes No
Yes No
f
Do you use a wheel chair?
Yes No
Yes No
g
Do you use any other equipment?
Yes No
Yes No
h
If you have required assistance with everyday activities in the past 2 years, please explain
i
In the past 5 years have you:
Self
Spouse
j
been confined to a hospital?
Yes No
Yes No
k
nursing home?
Yes No
Yes No
l
had home care?
Yes No
Yes No
m
had long-term care?
Yes No
Yes No
n
received rehabilitation?
Yes No
Yes No
o
Please describe your particular health problems
p
Prescribed medications
q
Do you currently own a long-term care policy?
Yes No
Yes No
Long-Term Care Quote Selections
16
Benefit period desired
(Average stay in a nursing facility is about 3 years) 
17
Daily Benefit - nursing home coverage
18
Daily benefit - home & community care
19
How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?
The average cost per month is $5,000 which could be more depending on area of country 
20
Inflation protection/cost-of living adjustment
Most needed for younger applicants 
Comments or Questions:
21
22
Deliver quote via: 
E-Mail Fax Regular Mail
Telephone
No coverage of any kind is bound or implied by submitting information via this online form
We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

By completing this form, you are acknowledging your understanding of and agreement with these terms

YES! I Agree