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Long Term Care

ALL INQUIRIES ARE CONFIDENTIAL.

Long Term Care Insurance Request & Preliminary Questions Form. 

Your information is encrypted from the start, and remains so during the entire process.

We want to provide the convinience, and take the hassle of multiple applications away. We provide quotes within 48 hours, in most cases. 

* Required


 

First Name:: *
Last Name:: *
Street Address: *
City: *
Zip Code: *
State: *
Phone number: *
Email:: *
Date of Birth: *
Your Gender: *
Status: *
Height: *
Weight: *
Use of Tobacco?(includes: patch, cigars, cigarettes,pipe, snuff, gum): *
Policy Type Wanted: *
Daily Benefit (increments of $10): *
Benefit Periods: *
Elimination Period(s): *
Inflation Options:
Riders:
Payment Options:
State Written In:
State Client Resides In:
Date of last Doctor physical: *
Citizenship and legal status: *
Spouse/Other Last Name:
Spouse/Other First Name:(Health):
Spouse/Other Date of Birth:
Gender:
-Height:
-Weight:
Tobacco User?:
Medical Condition diagnostic? If yes, indicate when, treatment followed, and last follow up.: *
List of medications and the reasons (if none, enter NO): *
Medical Procedures & Operations(past and scheduled): *
Moving violations (list all applicable: DUI, suspension or reckless driving history during the last 3 years): *
Cholesterol Level (Provide numbers & Chol/HDL ratio, if known, if not, enter don't know): *
Other Activities & Hobbies ( scuba diving, sky diving, stunt,private pilots, etc) list all applicable: *
Foreign Travel- Past and Futur (list all your trips outside of the US & Canada): *
What is desired More:
Yearly Income & Occupation:
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Please click "Submit" to forward your information. Our dedicated staff will diligently handle your request for quotes, and your Agent will contact you as soon as possible. Remember that we look for the best policy, consistent with your needs, conditions, and availability. Because we are not bound by the policies of a single carrier, you have many offers from many sources to choose from. We thank You for entrusting us with such an important part of your financial future.