For Consumers - Long Term Care and Medicare

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Questions to obtain a quote!
All these questions have significance to obtain a proposal for Long Term Care Insurance.
Sorry for this statement, but it has to be included!
Please note that you will receive a summary only. All company documents and the NAIC Shopper's guide will be required to be given to the customer before any such information can be valid. The final decision for all rates and policies would only be determined after full underwriting by the insurance company and the actual policy has be issued. Anything else is just an estimate and is not binding in any way to any insurance company or potential customer.
Person Requesting Information?*
First Last
State of Residence?*
Marital Status*
Domestic Partner discount is available from most companies.
Domestic Partners are two people living in a committed relationship for at least 3 years, not married to anyone else, sharing basic housing and living expenses. If related, they must be the same generation of the same family.
- Single / Widow
- Married
- Domestic Partner
Date of Birth?*
MM
DD
YYYY
Height?
Weight?
Your General Health?
Please indicate your general health. Any medications. Any conditions currently and in the last 5 years.
Preferred discount is available, please indicate if you feel you fall into this area.
If you don't feel comfortable at this time to give info, we will supply the quote at the standard rate.
Name - Spouse / Partner?
Date of Birth - Spouse / Partner
MM
DD
YYYY
Height - Spouse/Domestic Partner?
Weight - Spouse / Domestic Partner
General Health - Spouse / Partner
Please indicate your general health. Any medications. Any conditions currently and in the last 5 years.
Preferred discount is available, please indicate if you feel you fall into this area.
If you don't feel comfortable at this time to give info, we will supply the quote at the standard rate.
Email*
Enter Email Confirm Email
Mail me the information!
- Mail me the quote in addition to email
Address
Street Address City State ZIP Code
Phone Number? (Optional)
Is there anything else you would like us to know?
Click Submit to send your information!
When you click submit, you will be able to download the NAIC "A Shopper's Guide to Long-Term Care Insurance"
You will receive your quote in 24-48 hours.
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Questions to obtain a quote!

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