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 MM slash DD slash YYYY Gender M F HeightFeet plus inches (example 5'8") Weight Are you married? Yes No Spouse's Name*What is your Spouse's name? First Last Spouse's Date of BirthWhat is your Spouse's birth date? MM slash DD slash YYYY Is your spouse also applying?Is your spouse also applying? Spouse also applying? Do you smoke? Yes No Does your spouse smoke? Yes No Are you diabetic? Yes No Is your spouse diabetic? Yes No Are you insulin dependent? Yes No Is your spouse insulin dependent? Yes No Do you use a cane? Yes No Does your spouse use a cane? Yes No Do you use a walker? Yes No Does your spouse use a walker? Yes No Do you use a wheel chair? Yes No Does your spouse use a wheel chair? Yes No Do you use any other equipment? Yes No Does your spouse use any other equipment? Yes No If 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? Yes No has your spouse been confined to a hospital? Yes No have you been confined to a nursing home? Yes No has your spouse been confined to a nursing home? Yes No have you had home care? Yes No has your spouse had home care? Yes No have you had long-term care? Yes No has your spouse had long-term care? Yes No have you received rehabilitation? Yes No has your spouse received rehabilitation? Yes No Please describe your particular health problems:Self:Spouse:Your Prescribed medicationsYour Spouse's Prescribed medicationsDo you currently own a long-term care policy? Yes No Does your spouse currently own a long-term care policy? Yes No Medical 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