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 LTC Quote 
Form: ltc Quote
Long Term Care Insurance Quote




Contact Information
First Name:
Last Name:
Daytime Telephone:
Evening Telephone:
Email:
Address:
City:
State:
Zip:
About You
Your Birth Date
Your Gender
 Male Female
Your Height
Feet plus inches
(example 5'6")
Your Weight
Are You Married?
 Yes No
Spouse's Birth Date
Please Complete For Self/Spouse
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
  Self Spouse
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 policy?
Yes No
Yes No
Long-Term Care Quote Selections
Benefit period desired
(Average stay in a nursing facility is about 3 years)
Daily Benefit - nursing home coverage
Daily benefit - home & community care
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
Inflation protection/cost-of living adjustment
Most needed for younger applicants
Comments or Questions
Deliver quote via
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No coverage of any kind is bound or implied by submitting information via this online form
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By completing this form, you are acknowledging your understanding of and agreement with these terms


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