Long-Term Care Quote

Please complete the following information, if you would like to obtain a quote .  This is not an application. If you would like to have coverage, an application will be sent to you.

All information is confidential and will be used solely for the purpose of providing a quote for you.

Personal Information

Name
Email Address
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Fax Number
Birth Date
Gender
Height (example 5'8")
Weight (lbs.)
Are you married?
If so, Spouse's Birth Date
Fill in spouse if spouse is also applying
Do you smoke?
Spouse smoke?
Are you diabetic?
Spouse diabetic?
Are you insulin dependent?
Spouse insulin dependent?
Do you use a cane?
Spouse use a cane?
Do you use a walker?
Spouse use a walker?
Do you use a wheelchair?
Spouse use a wheelchair?
Do you use any other equipment?
Spouse use any other equipment?
Please explain if you have required assistance with everyday activities in the past 2 years:
Please explain if your spouse has required assistance with everyday activities in the past 2 years:
In the past 5 years have you: (check all that apply)
Please describe your particular health problems:
In the past 5 years has your spouse: (check all that apply)
Please descirbe your spouse's particular health problems:
Prescribed Medications:
Spouse's Prescribed Medications:
Do you currently own a long-term care policy?
Does your spouse currently own a long-term care policy?
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:
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