Insurance Professionals - Long Term Care and Medicare

Broker/Agent Requesting Information*

First Last

Broker/Agent email address?*

Enter Email Confirm Email

Broker/Agent Phone number*

Questions to obtain a quote!

All these questions have significance to obtain a proposal for Long Term Care Insurance. Please obtain and enter the Height and Weight of the clients as there is a wide variance between the companies!

Client's resident State?*

Marital Status*

When you click Married or Domestic Partner, the box for the spouse will appear.

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

Name of Client

If you want to show on Quote, if not, names will be Valued Client and/or Spouse.

Gender?*

Male
Female

Client's expected rate class. If not sure, please enter as much health information as possible in the box near the bottom.

Smoker?

Yes
No

Date of Birth?

or Age!

Height?

Weight?

Name - Spouse / Partner?

Spouse / Partner Gender?

Male
Female

Spouses expected rate class. If not sure, please enter as much health information as possible in the box near the bottom.*

Spouse / Partner Smoker?

Yes
No

Date of Birth - Spouse / Partner

or Age - Spouse/Domestic Partner

Height - Spouse/Domestic Partner?

Weight - Spouse / Domestic Partner

Mail me the information!

Mail me the quote in addition to email

Address

Street Address City State ZIP Code

Anything else you need to let us know?

Enter any health information, medications, history that you may know. Also, If you want a quote from a specific company, enter it here with the benefits you are requesting. You can copy and paste from other documents.

Click Submit to send your information!

You will receive your quote in the next business day.

Comments

This field is for validation purposes and should be left unchanged.

This page is for Insurance Professionals working with LTCUSA.

Insurance Professional Quote Request

Questions to obtain a quote!

Click Submit to send your information!