How may we contact you?
Home Phone
Work Phone
FAX
E-mail

Send me "A Shoppers Guide to Long Term Care" [National Association of Insurance Commissioners]

Please complete as much of the following as you can at this time. Thank you.
If you are unsure about an option, simply leave it unselected. (Leave it as "Select One")
Yes, send the recommended plan.

Facility Care Daily Benefit Amount: Select One $50.00 $60.00 $70.00 $80.00 $90.00 $100.00 $110.00 $120.00 $130.00 $140.00 $150.00 $160.00 $170.00 $180.00 $190.00 $200.00 $210.00 $220.00 $230.00 $240.00 $250.00 $260.00 $270.00 $280.00 $290.00 $300.00
Facility Care Daily Benefit Amount represents the daily amount of coverage reimbursed by the insurance company for facility care. This would include nursing homes, assisted living facilities, residential care facilities and adult congregate care.

Benefit Period: Select One 2 Years 3 Years 4 Years 5 Years Life
Benefit Period represents the number of years your benefits will be paid from 2 years to life (unlimited).

Elimination Period: Select One 0 Days 7 Days 10 Days 20 Days 30 Days 60 Days 90 Days 180 Days
Elimination Period is like a deductible and represents the number of days at the beginning of your covered stay before your benefit payments actually begin. (The longer the elimination period, the lower your premium.)

Home Care Daily Benefit: Select One 0% 50% 75% 80% 100%
Home Care Daily Benefit represents 0%, 50%, or 100% of the Facility Care Daily Benefit for Home Care Benefits. These benefits include skilled home health care providers, adult day care, homemaker, hospice, and personal care services.

Cost of Living Adjustment (COLA): Select One None 5% Simple 5% Compound
Cost of Living Adjustment (COLA) increases both your facility and home health care benefits to keep pace with the rising cost of care.

Are you a smoker? Yes No

Health Condition: Please describe your overall health condition here. No physical examination is required for long term care insurance. An applicant need only answer a few simple questions.

Hospitalizations: Please describe any hospitalizations in the last 10 years.
[i.e. Reason, how long ago, results (i.e full recovery)]

Medications: Please list any medications currently being taken.
[i.e. Name of medication, amount taken daily, how long you've been taking it, reason you're taking it]

Special Requests or Questions about Long Term Care:

You may SUBMIT this Insurance Quote Request when you are finished or CLEAR this form to start again.