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If you would like a complimentary
consultation to receive information you need to determine
if long-term care insurance is appropriate for you and your
family, please take a few moments to complete this information
request form.
This site employs strictly
confidential email. Your name and information will NOT be given
out to ANY mailing lists. (*denotes
a required field )
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General
Information
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Name*:
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Date of
Birth:
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Spouses
Name:
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Date
of Birth:
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| E-mail
Address*:
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| Street
Address:
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| City:
State:
Zip:
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| Contact
Phone Number*:
Best time to call:
Morning
Afternoon
Evening |
| How
did you find this website?
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What
is your main reason for seeking coverage for long-term care?
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| Have
you looked at other carrier's quotes already?
Yes
No |
| If
so, who? (This will avoid duplication of quotes you already
have)
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| Do
you currently own a long-term care policy that you would like
to compare with other plans available?
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Health
Information
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Please answer the following quick questions
to help determine your eligibility for long-term care insurance.
Depending on your health, you may or may not be eligible for
long-term care insurance. Your health does not have to be perfect;
however, there are certain conditions that would prevent you
from being considered for long-term care insurance.
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| In
the past 5 years, have you or your spouse used tobacco products
including cigarettes, pipe, cigar or chewing tobacco? |
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You:
Yes
No
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Your
Spouse :
Yes
No
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| During
the past 10 years, have you been confined to a hospital, nursing
home, received home care or diagnosed or treated for any serious
condition? If so, please describe. |
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You:
Yes
No
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Your
Spouse:
Yes
No
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| Please
list all medications you are currently taking and what they are
for. |
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You:
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Your
Spouse:
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Comments
or Questions
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Please list any
additional comments or questions you have.
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