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Long Term Care Quote Form
Coverage that provides nursing-home care, home-health care, personal or adult day care for individuals above the age of 65 or with a chronic or disabling condition that needs constant supervision. LTC insurance offers more flexibility and options than many public assistance programs.
Name
*
Prefix
First
Last
Suffix
State of Residence
*
Date of Birth
*
MM
/
DD
/
YYYY
Gender
Please select
Male
Female
SSN #
Optional
Home Phone
*
###
-
###
-
####
Email
Tobacco User
Please select
Yes
No
Coverage Information:
Benefit Amount
*
$
Dollars
.
Cents
Benefit Payment Frequency
*
Please select
Daily
Monthly
Home Health Care
*
Please select
None
50%
100%
Elimination Period Days
*
The length of time from when you start receiving care until you wish to start receiving benefits from you policy. The longer the elimination period, the cheaper the premium will be. This should be calculated considering savings, assets, and other sources of funding that you can use for your long-term care needs.
Benefit Period Years
*
Significant medical History
*
Include current or historical back/spine treatment
Medications currently being taken
*
Include name and dosage
Join Applicant Name
Prefix
First
Last
Suffix
Tobacco User
Please select
Yes
No
Same Benefits as Primary
Please select
Yes
No
If Not Explain
Significant medical History
Include current or historical back/spine treatment
Medications currently being taken
Include name and dosage
Other Comments
Referring Agent?
Please select
Michael Pardee
Joel Doty
