Long Term Care Quote

	Coverage		Comprehensive
	Facility Care		X
	Home Care Services		X
	Restoration of Benefits		X
	Personal Care Advisor		X
	Respite Care		X
	Community Care		X
	Hospice Care		X
	Bed Reservations		X
	Spousal Discount		X
	5 Year Rate Guarantee		X
	Tax Status: Qualified		X
	Residential Care   Facility for Elderly		X

Complete the form below for your Free Quote.
Or call (877)566-5454 Toll Free

Customer Information
Full Name
E-mail
Street Address
City
State	-- Choose -- Alabama Arkansas Arizona California Colorado Connecticut Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maryland Michigan Mississippi Missouri Nebraska Nevada New Hampshire New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia West Virginia Wisconsin
Zip Code
Day Phone
Evening Phone
Best time to call:	AM    PM
Preferred Method of Contact:	Telephone   Email

Your Information:
Height:	2 3 4 5 6 7 ft. 0 1 2 3 4 5 6 7 8 9 10 11 in.
Weight:	lbs.
Gender:	Male    Female
Your Birthdate (Ages 18-84):	Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925
How would you classify your health?	Excellent Good Fair Poor
Do you have any serious health problems?	Yes   No Please give explaination in box below
Have you used any tobacco products in the last 12 months?	Yes    No

Spouse's Information:
Spouse's Name:
Height:	2 3 4 5 6 7 ft. 0 1 2 3 4 5 6 7 8 9 10 11 in.
Weight:	lbs.
Gender:	Male    Female
Spouse's Birthdate (Ages 18-84):	Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925
How would you classify your spouse's health?	Excellent Good Fair Poor
Does spouse have any serious health problems?	Yes   No Please give explaination in box below
Has spouse used any tobacco products in the last 12 months?	Yes    No

Coverages wanted:
Daily Benefit Amount:	$100 per day $110 per day $120 per day $130 per day $140 per day $150 per day $160 per day $170 per day $180 per day $190 per day $200 per day $210 per day $220 per day $230 per day $240 per day $250 per day $260 per day $270 per day $280 per day $290 per day $300 per day $310 per day $320 per day $330 per day $340 per day $350 per day
Benefit period desired:	2 Years 3 Years 4 Years 5 Years 8 Years Lifetime
Waiting period desired:	7 Days 30 Days 60 Days 90 Days 180 Days
Do you want Inflation Guard Benefits? (Optional):	Yes   No

Have you any serious health problems or other comments

 

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