Long Term Care Quote Request Long-Term Care Quote Request For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.Personal InformationSelect Your StatePlease Note: We only write insurance for these states.SelectCaliforniaAddressWhat is your address? Street Address Address Line 2 City ZIP Code Name*What is your name? First Last Telephone Number*What is your telepone number?Email Address*What is your email address? Birth Date Date Format: MM slash DD slash YYYY GenderMFHeightFeet plus inches (example 5'8")WeightAre you married?YesNoSpouse's Name*What is your Spouse's name? First Last Spouse's Date of BirthWhat is your Spouse's birth date? Date Format: MM slash DD slash YYYY Is your spouse also applying? Spouse also applying? Do you smoke?YesNoDoes your spouse smoke?YesNoAre you diabetic?YesNoIs your spouse diabetic?YesNoAre you insulin dependent?YesNoIs your spouse insulin dependent?YesNoDo you use a cane?YesNoDoes your spouse use a cane?YesNoDo you use a walker?YesNoDoes your spouse use a walker?YesNoDo you use a wheel chair?YesNoDoes your spouse use a wheel chair?YesNoDo you use any other equipment?YesNoDoes your spouse use any other equipment?YesNoIf you have required assistace with everyday activities in the past 2 years, please explain:Self:Spouse:In the past 5 years:have you been confined to a hospital?YesNohas your spouse been confined to a hospital?YesNohave you been confined to a nursing home?YesNohas your spouse been confined to a nursing home?YesNohave you had home care?YesNohas your spouse had home care?YesNohave you had long-term care?YesNohas your spouse had long-term care?YesNohave you received rehabilitation?YesNohas your spouse received rehabilitation?YesNoPlease describe your particular health problems:Self:Spouse:Your Prescribed medicationsYour Spouse's Prescribed medicationsDo you currently own a long-term care policy?YesNoDoes your spouse currently own a long-term care policy?YesNoMedical HistoryBenefit period desired(Average stay in a nursing facility is about 3 years)Select2 Years3 Years4 Years5 Years6 YearsLifetimeDaily Benefit - nursing home coverageSelectZero$40$50$60$70$80$90$100$110$120$130$140$150$160$170$180$190$200$210$220$230$240$250How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?The average cost per month is $3,500 which could be more depending on area of countrySelect0 Months1 Month2 Months3 Months4 Months5 Months6 MonthsUp to 1 YearInflation protection/cost-of living adjustmentMost needed for younger applicantsSelectNo Increase WantedSimple-5% Each YearCompounded-5%CaptchaPrint Form