Long Term Care Insurance Information Request
Note: The following information is kept confidential to ensure your privacy.
Name
Address
City
State
Please Select
Alabama
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North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
West Virginia
Wisconsin
Wyoming
Zip Code
Day Phone
Evening Phone
Fax
Email Address
Or... Continue for a Personalized Quote
Date of Birth
MM
01
02
03
04
05
06
07
08
09
10
11
12
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Height
4 Ft
5 Ft
6 ft
7 Ft
1
2
3
4
5
6
7
8
9
10
11
Weight
75
76
77
78
79
80
81
89
90
91
92
93
94
95
96
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
121
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
159
160
161
162
163
164
165
166
167
168
166-170
171-175
176-180
181-185
186-190
190-195
196-200
201-205
206-210
211-215
216-220
221-225
226-230
231-235
236-240
241-245
246-250
251-225
226-230
231-235
236-240
241-245
246-250
251-255
256-260
261-265
266-270
271-275
276-280
281-285
286-290
291-295
296-300
301-305
+ 310
Have you used tobacco within the past 24 months?
Yes
No
Type of Employment
Are you receiving any type of disability benefits?
Yes
No
Type of Coverage
Daily LTC Benefits
$
250
240
230
220
210
200
180
170
160
150
140
130
120
110
100
90
80
Benefit Period
1 year
2 years
3 years
4 years
5 years
Lifetime
Elimination Period
0 Days
20 Days
30 Days
60 Days
90 days
180 Days
365 Days
Inflation Protection
Yes
No
Home Health Care Benefit
Yes
No
Guaranteed Increase Benefit Option
Yes
No
Tax-Qualified Plan
Yes
No
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