Long-Term Care Insurance Application


Before you fill out this form make sure you have received a quote first because we represent different companies and need to know which application to send you. (Get a quote)

If you just want to get a ballpark idea of the cost go to QuickQuote.

States require paper applications to be filled out and submitted, online applications are not yet available for long term care insurance. After you receive a quote you fill out the form below we will email or mail your application (your choice) with instructions, and we have phone support if you need assistance with the forms.

At this stage you are only applying for approval and are not committed to the insurance or to the benefits of the plan. Approval takes 3-6 weeks. Once approved you will be sent a policy proposal and have by state law 30 days to keep it, change it, or cancel it.

We represent all the major long term care insurance carriers and do not have a preference. We will provide you with the lowest premiums for the benefits you select. The premiums are the same if you buy your insurance through us, another agent or agency, or directly from the company.

Please fill out the entire form. We do not sell or share your information.

If you are uninsurable see the Annuity option for more information.

Be sure you received a quote before filling out an application request.

Full Name :

Age

Health
Second Applicant:

Age

Health

Status
Single Married Partner/Sibling

Choose the insurance company.


If you are unsure of benefits read Plan Design. Not all companies have same benefits.

Choose your daily benefit.

Choose length of benefits.

Choose inflation protection

Choose elmination period.

Additional benefits or riders.
example: shared benefits, home care EP waiver, see brochures for optional benefits

I want the application sent by:
Email Postal Mail
I want to meet with a local agent: Yes No

Street Address, City, State, Zip
(required to send application)

E-mail:
(required to email application)

Phone: (entry required)
*home, work, cell or repeat email
Best days to contact you:
M-F Sat Sun
Best times to contact you: AM — PM



Call toll free 1-888-582-2464
or Email us if you have any questions.


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