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Long Term Care Insurance
buyers guide

 

For a long-term care insurance quote please fill out as much information as possible. This will help us to give you the most accurate quote.

	Your Information
Name
Address
City, State & Zip	CityState Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of 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 New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgina Washington West Virginia Wisconsin Wyoming Zip Code
Phone	include area code
Email	myself@xyz.com
Best time to contact	Daytime Evening
	Personal Information
Birth Date	mm/dd/yyyy
Gender	Male Female
Height	4 5 6 7 Feet --- 0 1 2 3 4 5 6 7 8 9 10 11 Inches
Weight	lbs.
Smoker	Yes No
	Include Spouse on quote?
Spouse's Name
Birth Date	mm/dd/yyyy
Gender	MaleFemale
Height	4 5 6 7 Feet --- 0 1 2 3 4 5 6 7 8 9 10 11 Inches
Weight	lbs.
Smoker	Yes No
	Health Information
Do you or spouse have Arthritis	Osteo Rheumatoid ----- MedicationsDosage and Frequency
Do you or spouse have Osteoporosis	MedicationsDosage and Frequency
Do you have Asthma, Empysema or COPD?	use tobacco or have within the past year. use oxygen. use steroids over 10mg. have activity limitations. ------- MedicationsDosage and Frequency
Do you or spouse have cancer?	MedicationsDosage and Frequency
Do you or spouse have a heart disease, irregular heart beat, or valve disease?	MedicationsDosage and Frequency
Do you or spouse have Diabetes?	MedicationsDosage and Frequency
Do you or spouse have Peripheral Vascular Disease? (Poor circulation in the extremitie)	Select Choice Diabetes Asthma, Emphysema, COPD Functional limitations used tobacco within the past two years Claudication Pain skin ulcers MedicationsDosage and Frequency
	Coverage Information
Type of coverage	New Coverage Add'l Coverage Replacement Coverage
Facility Benefit	50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250
Home Benefit	50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250
Benefit Period	1 year 2 year 3 year 4 year 5 year Unlimited
Waiting Period	None 30 Day 60 Day 90 Day 180 360 Day
Inflation Protection	None 5% Simple 5% Compound
Any Additional comments or requirements	type in the box.....