LTC Quotes From
Top-Rated Companies
For additional Information
Choose Your Daily Nursing Home Coverage
Benefit:
Select Daily Benefit --------->
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
**
( ** Required Fields)
How many days after care is needed would
you like the benefits to begin?
Select Waiting Period --------->
0 Days
20 Days
60 Days
100 Days
**
Benefit Period Desired:
Select Benefit Period --------->
1 Year
2 Years
3 Years
4 Years
5 Years
To Age 65
Lifetime
**
Do you want coverage for Home Care?
Select Daily Benefit Period --------->
N/A
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
Who would this quote be for?
Self
Spouse
Parent(s)
Child(ren)
Business Assoc.
Other
**
Marital Status:
Single, no dependents
Single, one dependent
Single, two dependents
Single, three dependents
Single, four dependents
Married, no children
Married, one child
Married, two children
Married, three children
Married, four children
**
First Name:
**
Middle Initial:
Last Name:
**
E-mail Address:
**
Address:
**
City:
**
State:
Alabama
Alaska Arizona Arkansas
California Colorado Connecticut
Connecticut Dist. Columbia
Florida
Georgia Hawaii Idaho
Illinois Indiana Iowa
Kansas Kentucky Louisiana
Maine Maryland Massachusetts
Michigan Minnesota Mississippi
Missouri Montana Nebraska
Nevada New Hampshire New Jersey
New Mexico NY Non-Bus NY Business
North Carolina North Dakota Ohio
Oklahoma Oregon Pennsylvania
Rhode Island South Carolina
South Dakota
Tennessee Texas Utah
Vermont Virginia Washington
West Virginia Wisconsin Wyoming
**
Zip:
**
Home Telephone:
**
Home Telephone:
Health Questions:
The following questions are
required for an accurate life quote. Please see our
Privacy Statement .
Gender:
**
Date of Birth:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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1925
Other
**
Height:
3 Feet
4 Feet
5 Feet
6 Feet
7 Feet
0 Inches
1 Inches
2 Inches
3 Inches
4 Inches
5 Inches
6 Inches
7 Inches
8 Inches
9 Inches
10 Inches
11 Inches
**
Weight (pounds):
**
Occupation:
Smoker or Non Smoker:
Non-Smoker
Smoker - under 1
pack a day
Smoker - 1 - 2 packs a
day
Smoker - over 2
packs a day
--------------------------------
Cigars
Pipe
Patch
Chewing Tobacco
**
Recently quit smoking:
Not Applicable
Less than 1 year
Over 1 year ago
Over 2 years ago
Over 3 years ago
Over 4 years ago
Over 5 years ago
Medical Information:
‡
You are
not required
to complete the medical health questions below to receive your LTC quotes;
however, this information is necessary to provide you with an accurate quote.
In the past 2 years, have you needed
assistance with daily activities?
yes
no
**
If yes, please explain:
In the past 5 years, have you been
hospitalized or received in home care?
yes
no
**
If yes, please explain:
Do you have any health conditions or take
any prescription medications?
yes
no
**
If yes, please explain:
US Citizen/Perm Resident:
**
Have you ever been declined or rated for
LTC insurance?
**
Additional contact information
request.
Best time to contact you:
Anytime
Morning at Home
Morning at Work
Afternoon at Home
Afternoon at Work
Evening at Home
Evening at Work
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