Long Term Care Quote form

Please answer the following questions to the best of your ability and knowledge. If you do not know the answer to any of the questons just leave it blank and we will address the issue when we contact you.

Name of first insured:

Name of second insured:

Date of birth (First insured):

Select Date

Date of birth (Second insured):

Select Date

Address:

City:

State:

Zip Code:

Phone number:

Cell number:

Email address:

Approximately how much daily rate would you like to receive:

Benefit waiting period:

30 days
60 days
90 days
120 days
180 days

Current major health issues:

Submit

Report a Claim

Certificate Request

Have all polices expire on the same day
Having all policies expire on the same day lets you simplify the process of administering all your policies at the same time. It gives you the ability to have a complete picture of your program and your budget. (FYI- Insurance agents love to split up dates in order to retain the business via confusion and the hassle factor.)

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