Long-Term Care Insurance Online Quote Request

Personal Information

First Name (required)

Last Name (required)

Your Email (required)

Phone Number (required)

State (required)

Who Referred You (required)

Birth date (mm/dd/yyy)

Your Gender (required)—Please choose an option—Malefemale

Height (example 5'8")

Weight (lbs)

Are you Married? (required)—Please choose an option—YesNo

Your Quote Information

Do you smoke —Please choose an option—YesNo

Are you diabetic —Please choose an option—YesNo

Are you insulin dependent—Please choose an option—YesNo

Do you use a cane, walker, or wheelchair—Please choose an option—YesNo

Do you use any other equipment —Please choose an option—YesNo

Please explain if you have required assistance with everyday activities in the past 2 years

In the past 5 years have you:

been confined to a hospital —Please choose an option—YesNo

been confined to a nursing home —Please choose an option—YesNo

had home care —Please choose an option—YesNo

had long-term care? —Please choose an option—YesNo

received rehabilitation —Please choose an option—YesNo

Prescribed Medications

Please describe your particular health problems

Spouse Information

Spouse's Name

Spouse's Birth Date

Height (spouse)

Weight (spouse)

spouse smoke —Please choose an option—YesNo

spouse diabetic —Please choose an option—YesNo

spouse insulin dependent —Please choose an option—YesNo

spouse use a cane, walker, or wheelchair—Please choose an option—YesNo

spouse use any other equipment —Please choose an option—YesNo

Please explain if your spouse has required assistance with everyday activities in the past 2 years

In the past 5 years has your spouse had:

been confined to a hospital —Please choose an option—YesNo

nursing home —Please choose an option—YesNo

had home care —Please choose an option—YesNo

had long-term care —Please choose an option—YesNo

received rehabilitation —Please choose an option—YesNo

Spouse's Prescribed Medications

Please describe your spouse's particular health problems