For a long-term care insurance quote, please click on the email link below and enter the following information.
You can copy this block of questions and then paste it into the email you will be sending to us. Be sure to fill in
the requested information.
Name:
Spouse's Name:
Date of birth:
Spouse's date of birth:
Do you or your spouse smoke cigarrettes? If yes, who does?
Rate your health (Excellent, Good/Average, Poor):
Height:
Weight:
Rate your spouse's health (Excellent, Good/Average, Poor):
Spouse's height:
Spouse's weight:
Amount of monthly benefit desired (typical monthly costs are about $4,000): $
How long do you want the benefits to last (i.e. 4 years, 5 years, lifetime, etc.):
Do you want a cost of living adjustment rider (to fight inflation)? - Yes or No:
How do you prefer to be contacted? email, phone, mail, etc.
