Long-Term Care Quote Request Form

Long Term Care

Please complete the request form in order for our insurance carries to provide you with an accurate quote.

Long-Term Care Quote Request Form
Who will this quote be for?
Marital Status:
Your State:
City:
Choose Your Daily Nursing Home Coverage Benefit:
How many days after care is needed would you like the benefits to begins?
Benefit Period Desired:
Do you want coverage for Home Care?
First Name:
Last Name:
Contact Phone:
Alt Phone:
E-Mail:
Best time to call:
Birth Date:	Year
Gender:
Height*	Feet Inches
Weight*	lbs
Do you smoke or use tobacco products?
In the past 2 years, have you needed assistance with daily activities? (explain below)
In the past 5 years, have you been hospitalized or received in home care? (explain below)
Do you have any health conditions or take any prescription medications? (explain below)
Need Quotes within:
How where you referred to this website:
Additional Health Information or Request:
What is the Waiting Period? The waiting period is the number of days you choose to wait, between the time you file your long term care insurance claim, and the time daily benefit payments begin. What is the Daily Benefit?The daily benefit is the dollar figure that will be paid to an individual on a daily basis for long term care expenses.