Long Term Care Insurance

Thank you for your interest.

One of the greatest potential risks faced by America’s elderly is the need for long-term care. Long-term care insurance transfers a portion of the risk of long-term care expenses to an insurance company helping to protect you and your family from potentially devastating expenses.

After completing the form, please click on the “Submit” button. Your information will be emailed to our offices and we will process your request. All information will be kept confidential.

 

Please use the form below to contact us.






Contact Information

Name
Email
Phone
Address1
City
State
Zip

Personal Information

 
M/F

Male
Female
Age

Height

Weight

Policy Information

 
What daily benefit would you like your long-term care policy to provide?

What daily benefit would you like your long-term care policy to provide?

If you need long-term care, what’s your desired waiting period before benefits begin?

If you need long-term care, how long do you want to be eligible for benefits?

Lifetime
3 years or more
12 to 35 months
Do you want your policy to include home-health care coverage?

Yes
No
Do you want your policy to have the option to increase with inflation?

Yes
No
Briefly describe any medical events in the past 10 years that have required hospitalization or surgery:

Additional Considerations

 
Are you a tobacco user?

Yes
No
How would you describe your health?

Excellent
Very Good
Good
Poor

These quotes do not guarantee coverage and
actual premiums may differ from the quotes provided

   
Is your spouse also applying for Long-Term Care?

Yes
No

Spouse Contact Information

Name
Email
Phone
Address1
City
State
Zip

Spouse Personal Information

 
M/F

Male
Female
Age

Height

Weight

Spouse Policy Information

 
What daily benefit would you like your long-term care policy to provide?

What daily benefit would you like your long-term care policy to provide?

If you need long-term care, what’s your desired waiting period before benefits begin?

If you need long-term care, how long do you want to be eligible for benefits?

Lifetime
3 years or more
12 to 35 months
Do you want your policy to include home-health care coverage?

Yes
No
Do you want your policy to have the option to increase with inflation?

Yes
No
Briefly describe any medical events in the past 10 years that have required hospitalization or surgery:

Spouse Additional Considerations

 
Are you a tobacco user?

Yes
No
How would you describe your health?

Excellent
Very Good
Good
Poor