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Long Term Care Insurance

One of the greatest potential risks faced by America's elderly is the need for long-term care. Long-term care insurance transfers a portion of the risk of long-term care expenses to an insurance company helping to protect you and your family from potentially devastating expenses. After completing the form, please click on the "Submit" button. Your information will be emailed to our offices and we will process your request. All information will be kept confidential.

After completing the form, please click on the "Submit" button. Your information will be emailed to our offices and we will process your request. All information will be kept confidential.

» Required Fields

Contact Information

» Name:

Address:

City:

State:

AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDCDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontUS Virgin IslandsWashingtonWisconsinWest VirginiaWyoming

Zip:

» Phone:

» Email Address:

Personal Information

M/F:

Male Female

Date of Birth:

Height:

Weight:

Policy Information

What daily benefit would you like your long-term care policy to provide?

$50$60$70$80$90 $100$110$120$130$140$150$160$170$180$190$200$210$220$230$240$250$260$270$280$290$300$350$400$450$500

If you need long-term care, what's your desired waiting period before benefits begin?

0 - 30 Days31 - 100 Days101 - 365 Days

If you need long-term care, how long do you want to be eligible for benefits?

Lifetime 3 Years or More 12 to 35 months"

Do you want your policy to include home-health care coverage?

Yes No

Do you want your policy to have the option to increase with inflation?

Yes No

Briefly describe any medical events in the past 10 years that have required hospitalization or surgery:

Additional Considerations

Are you a tobacco user?

Yes No

Are you a pilot?

Yes No

How would you describe your health?

Excellent Very Good GoodPoor

Any additonal information to consider as we process your request?

Is Your Spouse Also Applying for Long-Term Card Insurance?

(if no, please skip to the bottom of the form)

Yes No

Spouse Contact Information

Name:

Spouse Address:

City:

State:

AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDCDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontUS Virgin IslandsWashingtonWisconsinWest VirginiaWyoming

Zip:

Spouse Phone:

Spouse Email Address:

Spouse Policy Information

What daily benefit would you like your long-term care policy to provide?

$50$60$70$80$90 $100$110$120$130$140$150$160$170$180$190$200$210$220$230$240$250$260$270$280$290$300$350$400$450$500

If you need long-term care, what's your desired waiting period before benefits begin?

0 - 30 Days31 - 100 Days101 - 365 Days

If you need long-term care, how long do you want to be eligible for benefits?

Lifetime 3 Years or More 12 to 35 months"

Do you want your policy to include home-health care coverage?

Yes No

Do you want your policy to have the option to increase with inflation?

Yes No

Briefly describe any medical events in the past 10 years that have required hospitalization or surgery:

Spouse Additional Considerations

Is your spouse a tobacco user?

Yes No

Is your spouse a pilot?

Yes No

How would you describe your spouse's health?

Excellent Very Good GoodPoor

Any additonal information to consider as we process your request?

These quotes do not guarantee coverage and
actual premiums may differ from the quotes provided.

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