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Long-Term Care
Quote

Filter Type:
Personal Information
Name:
Email:
Day Phone:
Home Phone:
Address:
City:
State:
Zip:
Birthdate:
Height:
Weight:
 Male Female
 Married Single
Applicant
Do you smoke?
 No Yes
Are you diabetic?
 No Yes
Are you insulin dependent?
 No Yes
Do you use a cane?
 No Yes
Do you use a walker?
 No Yes
Do you use a wheel chair?
 No Yes
Do you use any other equipment?
 No Yes
In the past 5 years have you...
been confined to a hospital?
 No Yes
lived in a nursing home?
 No Yes
had home care?
 No Yes
had long-term care?
 No Yes
received rehabilitation?
 No Yes
Do you currently own a long-term care policy?
 No Yes
If you have required assistance with everyday activities in the past 2 years, please explain:
Please describe your particular health problems.
Prescribed medications:
Spouse
Do you smoke?
 No Yes
Are you diabetic?
 No Yes
Are you insulin dependent?
 No Yes
Do you use a cane?
 No Yes
Do you use a walker?
 No Yes
Do you use a wheel chair?
 No Yes
Do you use any other equipment?
 No Yes
In the past 5 years have you...
been confined to a hospital?
 No Yes
lived in a nursing home?
 No Yes
had home care?
 No Yes
had long-term care?
 No Yes
received rehabilitation?
 No Yes
Do you currently own a long-term care policy?
 No Yes
If you have required assistance with everyday activities in the past 2 years, please explain:
Please describe your particular health problems.
Prescribed medications:

Long-Term Care Quote Selections
Benefit period desired:
Daily Benefit - nursing home coverage
Daily benefit - home & community care
Inflation protection/cost-of living adjustment:
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.
When is the best time to call and discuss your quote?
 Morning Afternoon Evening Anytime Other
If other, please specify:

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