Long Term Care Insurance Quote Request

Name

First

Last

State

Gender

Male

Female

Phone Number

Type:

E-mail

Which do you prefer:

Call me to discuss this further

Please provide me with a proposal based on the information shown below

Best times to reach you?

Basic information needed to generate a fairly accurate quote:

Daily Benefit Desired:

Any particular features desired?

Yes

No

If yes, please describe. If no, we will include common riders and features.

Date of Birth

Height (inches)

Weight (lbs)

Tobacco Use?

Yes

No

If yes, what type of tobacco? How often do you use tobacco? How long have you used tobacco?

Do you have (or have had) any significant medical illnesses, ailments or injuries?

Yes

No

If yes, please briefly describe:

Do you currently take any medications?

Yes

No

If yes, which medications? Dosage? How often? How long have you been taking them?

Other helpful information (not required at this point):

Total Existing Coverage:

Description: (When was policy put in place? Benefit period? Elimination period? 100% Home care? Riders included?)

Enter information if known:

Blood Pressure

Total Cholesterol

Total / HDL Ratio

Foreign Travel Planned?

Yes

No

If yes, where? For how long? Is it for business, vacation, other?

Do you have any moving violations?

Yes

No

If yes, what type of violation? When did they occur?

Significant Sports / Activities (rock climbing, piloting, scuba diving, racing, sky diving, etc.)

Family History (parents & siblings cause of death, any severe medical conditions, age, diabetes, etc.)

Additional information (including any information on a spouse or others if a quote desired for them.)

Address:

City

Postal / Zip Code

Alternate Phone Number

Type:

*Premium indications provided are not firm quotations and are not bindable. Terms, limits, deductibles, conditions and price may change upon receipt, review and acceptance of a completed application and supporting documentation by the company.

A binding quotation will not be issued without the company's full underwriting due dilligence.