Long Term Care Insurance Policy Quote

LONG-TERM CARE INSURANCE POLICY QUOTE REQUEST Please complete the following information if you would like to obtain a quote on a Long-Term Care Insurance Policy.  Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you. Personal Information What is your name? Last First Middle What is your e-mail address? e-mail What is your address? Street City State Select Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip What is your telephone number? Day Evening What is your fax number? Fax What is your birth date? Birth Date What is your gender? Gender Male Female What is your height? Feet plus inches (example 5'8") What is your weight? Weight Are you married? Yes No Spouse's Birth Date? Fill in spouse if spouse is also applying   Self Spouse Do you smoke? Yes No Yes No Are you diabetic? Yes No Yes No Are you insulin dependent? Yes No Yes No Do you use a cane? Yes No Yes No Do you use a walker? Yes No Yes No Do you use a wheel chair? Yes No Yes No Do you use any other equipment? Yes No Yes No If you have required assistance with everyday activities in the past 2 years, please explain In the past 5 years have you: been confined to a hospital? Yes No Yes No nursing home? Yes No Yes No had home care? Yes No Yes No had long-term care? Yes No Yes No received rehabilitation? Yes No Yes No Please describe your particular health problems Prescribed medications Do you currently own a long-term care insurance policy? Yes No Yes No Long-Term Care Insurance Policy Quote Selections Benefit period desired (Average stay in a nursing facility is about 3 years) Select 2 Years 3 Years 4 Years 5 Years 6 Years Lifetime Daily Benefit - nursing home coverage   Select Zero $40 $50 $60 $70 $80 $90 $100 $110 $120 $130 $140 $150 $160 $170 $180 $190 $200 $210 $220 $230 $240 $250 Daily benefit - home & community care   Select Zero $40 $50 $60 $70 $80 $90 $100 $110 $120 $130 $140 $150 $160 $170 $180 $190 $200 $210 $220 $230 $240 $250 How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc? The average cost per month is $5,000 which could be more depending on area of country Select 0 Months 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months Up to 1 Year Inflation protection/cost-of living adjustment Most needed for younger applicants Select No Increase Wanted Simple-5% Each Year Compounded-5% Best Time to Contact You Please let us know the best time to call and discuss your quote. Morning Afternoon Evening Anytime Or specify other: