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Long Term Care Insurance Quote
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First Name:
Last Name:
Date of Birth:
(example: 06-04-64)
Gender:
Select
Male
Female
Address
City:
State:
Select State
Alabama
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Arkansas
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Florida
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North Carolina
North Dakota
Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone:
Best time to call:
Choose Time
7 A.M. to 9 A.M.
9 A.M. to 11 A.M.
11 A.M. to 1 P.M.
1 P.M. to 3 P.M.
3 P.M. to 5 P.M.
5 P.M. to 7 P.M.
7 P.M. to 9 P.M.
9 P.M. to 11 P.M.
Alternate Phone:
Best time to call:
Choose Time
7 A.M. to 9 A.M.
9 A.M. to 11 A.M.
11 A.M. to 1 P.M.
1 P.M. to 3 P.M.
3 P.M. to 5 P.M.
5 P.M. to 7 P.M.
7 P.M. to 9 P.M.
9 P.M. to 11 P.M.
Email Address:
Insured Occupation:
Spouse to be included?:
Yes
No
Benefit Period:
1 year
2 years
3 years
4 years
Lifetime
Choose Your Daily Nursing Home Coverage Benefit:
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
per day
Do you want coverage for Home Care?
Yes
No
If Yes, Choose
Daily Benefit
$80
$90
$100
$110
$120
$130
$140
$150
$160
$170
$180
$190
$200
$210
$220
$230
$240
Height
4"10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
Select
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
(cannot exceed nursing home benefit)
How many days after care is needed would you like the benefits to begin (i.e. - "Elimination Period)?
0 Days
30 Days
60 Days
90 Days
180 Days
365 Days
Would you Like Inflation Guard Benefits?
Yes
No
Your Height
4"10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
Select
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
Your Weight
lbs.
Health History:
Have you ever been treated for cancer, diabetes, or cardiovascular disorders in your life?
If yes, please describe
Beneficiary:
Name:
Age:
Select
1
2
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95
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97
98
99
100
101
102
103
104
105
106
107
108
109
110
Relationship:
What medications are you taking?
If yes, please give dosage and frequency
Have you had 2 or more moving violations in the last 2 years or any DUI's in the last 5 years?
If yes, please describe
Current Long Term Care Insurance Company, if Any:
Current Monthly Premium:
Comments or Questions
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