Long Term Care Quote Request

For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.

Personal Information

Select Your State

Please Note: We only write insurance for these states.

Address

What is your address?

Street Address Address Line 2 City ZIP Code

Name*

What is your name?

First Last

Telephone Number*

What is your telepone number?

Email Address*

What is your email address?

Birth Date

Gender

M
F

Height

Feet plus inches (example 5’8″)

Weight

Are you married?

Yes
No

Spouse's Name*

What is your Spouse’s name?

First Last

Spouse's Date of Birth

What is your Spouse’s birth date?

Is your spouse also applying?

Spouse also applying?

Do you smoke?

Yes
No

Does your spouse smoke?

Yes
No

Are you diabetic?

Yes
No

Is your spouse diabetic?

Yes
No

Are you insulin dependent?

Yes
No

Is your spouse insulin dependent?

Yes
No

Do you use a cane?

Yes
No

Does your spouse use a cane?

Yes
No

Do you use a walker?

Yes
No

Does your spouse use a walker?

Yes
No

Do you use a wheel chair?

Yes
No

Does your spouse use a wheel chair?

Yes
No

Do you use any other equipment?

Yes
No

Does your spouse use any other equipment?

Yes
No

If you have required assistace with everyday activities in the past 2 years, please explain:

Self:

Spouse:

In the past 5 years:

have you been confined to a hospital?

Yes
No

has your spouse been confined to a hospital?

Yes
No

have you been confined to a nursing home?

Yes
No

has your spouse been confined to a nursing home?

Yes
No

have you had home care?

Yes
No

has your spouse had home care?

Yes
No

have you had long-term care?

Yes
No

has your spouse had long-term care?

Yes
No

have you received rehabilitation?

Yes
No

has your spouse received rehabilitation?

Yes
No

Please describe your particular health problems:

Self:

Spouse:

Your Prescribed medications

Your Spouse's Prescribed medications

Do you currently own a long-term care policy?

Yes
No

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

Yes
No

Medical History

Benefit period desired

(Average stay in a nursing facility is about 3 years)

Daily Benefit – nursing home coverage

How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?

The average cost per month is $3,500 which could be more depending on area of country

Inflation protection/cost-of living adjustment

Most needed for younger applicants

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Long-Term Care Quote Request

Personal Information

Medical History