|
First Name:
|
|
Last Name: |
|
Date of
Birth:
(example: 06-04-64)
|
|
Gender:
|
|
|
Address |
|
City:
|
|
|
State:
|
|
Zip Code:
|
|
| Phone:
|
|
Best time to call:
|
|
|
Alternate Phone:
|
|
Best time to call:
|
|
| Email Address:
|
|
Insured Occupation:
|
|
|
Spouse to be included?:
|
Yes
No
|
Benefit Period:
|
|
|
Choose Your Daily Nursing Home Coverage Benefit:
|
per day
| Do you want coverage for Home Care?
|
Yes No
|
|
Height
|
(cannot exceed nursing home benefit)
|
How many days after care is needed would you like the benefits to begin (i.e. - "Elimination Period)?
|
|
|
Would you Like Inflation
Guard Benefits?
|
Yes No
|
Your Height
|
|
|
Your Weight
|
lbs.
|
Health History:
Have you ever been treated for cancer, diabetes, or cardiovascular
disorders in your life?
|
|
|
What
medications are you taking?
|
|
|
Have
you had 2 or more moving violations in the last 2 years or any DUI's in the
last 5 years?
|
|
Current
Long Term Care Insurance Company, if Any:
|
|
|
Current Monthly Premium:
|
|
Comments or Questions
|
|
|
|
|
|
Click Button Below When Done
Please Click Only Once . . . May take up to 30 seconds!
|