Long Term Care Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

 

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Name

Email Address

Address

Phone Number

Alternate Telephone

Fax Number

Birth Date

Gender

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Height (example 5'8")

Weight (lbs.)

Are you married?

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If so, Spouse's Birth Date

Height (spouse)

Weight (spouse)

Do you smoke?

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Spouse smoke?

Please provide the required field.

Are you diabetic?

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Spouse diabetic?

Please provide the required field.

Are you insulin dependent?

Please provide the required field.

Spouse insulin dependent?

Please provide the required field.

Do you use a cane?

Please provide the required field.

Spouse use a cane?

Please provide the required field.

Do you use a walker?

Please provide the required field.

Spouse use a walker?

Please provide the required field.

Do you use a wheelchair?

Please provide the required field.

Spouse use a wheelchair?

Please provide the required field.

Do you use any other equipment?

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Spouse use any other equipment?

Please provide the required field.

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 provide the required field.

Please describe your particular health problems:

In the past 5 years has your spouse: (check all that apply)

Please provide the required field.

Please describe your spouse's particular health problems:

Prescribed Medications:

Spouse's Prescribed Medications:

Do you currently own a long-term care policy?

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Does your spouse currently own a long-term care policy?

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Please let us know the best time to call and discuss your quote.

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Or Specify Other:

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