Custom Price Quotes

For a list of sample quotes, click here. Otherwise, continue on this page for a complimentary customized price quote. Your timing is perfect! The earlier you enroll in Long Term Care Insurance, the cheaper it is for you. Your rate will be based upon the age that you are when you submit your application. DO THIS while you are still young, active and healthy enough to qualify. Remember, not everyone can get this coverage. If you wait until YOU NEED IT, it may be too late! Please act now. To receive a complimentary, no obligation insurance quote for Long Term Care Insurance, please fill in parts 1 and 2 of the form provided. An insurance agent will contact you. Fields marked with an asterisk are required to be filled in. PERSONAL PROFILE - Part 1

*Your Name:		Spouses Name:
*Date of Birth: (MM/DD/YYYY)		Spouse's Date of Birth: (MM/DD/YYYY)
Sex		Sex
Male Female		Male Female
Street		*Daytime phone
City		Evening phone
State		*E-Mail
*ZIP Code

HEALTH PROFILE - Part 2 It's a good idea to fill out the following brief health profile. Why? Some carriers have "Preferred" rates of up to 20% lower premiums for those who qualify. All carriers accept varying health histories at their standard rates. Other carriers may apply substandard rates for an individual with significant health history. The information on this form helps us to determine the appropriate carrier for you. This is not an application, and the information provided will be considered confidential. A yes answer does not mean that you do not qualify for coverage. You should probably not purchase long term care insurance unless you have at least $25,000 in annual household income and at least $100,000 in assets, (unless others are willing to help pa

*Your Name:		Spouses Name:
*Date of Birth: (MM/DD/YYYY)		Spouse's Date of Birth: (MM/DD/YYYY)
*You		Spouse
Height		Height
Weight		Weight

Please answer the following questions for yourself and, if applicable, your spouse. All questions are required in order to generate an accurate quote.

	*You	Spouse
Hospitalized in the last two years:	Yes No	Yes No
Any help needed in Bathing, Dressing, Eating, Transferring, Toileting, or Continence?	Yes No	Yes No
Tobacco use in the last two years?	Yes No	Yes No
Any use of adaptive devices (i.e. cane, walker, wheelchair)?	Yes No	Yes No
Any history of cancer?	Yes No	Yes No
Diabetes?	Yes No	Yes No
Heart disease?	Yes No	Yes No
Memory loss?	Yes No	Yes No
Any other major health history? Please describe: