Long-Term Care Insurance Quote/Apply Form

Quotes based on current rates from the top companies as of

We recommend you first read QuickQuote and Guide which will give you an idea of the cost of long term care insurance before filling out this form.

If you are interested in seeing if you qualify complete this short form and we will email you a quote with the lowest rates and a brochure from top insurance companies explaining the coverage.

A licensed agent and financial advisor will help you with the application process.

We are the largest online long term care insurance agency. We represent all the major long term care insurance carriers.

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.

We respect your privacy and do not share this information.
Name or Initials:
Age
Spouse/Other Name or Initials:
Age

Status
Single Married* Partner* Sibling*
* discounts: spouses, two people share living expenses, two applying-two approved, two applying-one approved, one spouse applying

Does either applicant take prescription medications?
*specify what meds and which applicant
Yes No

Does either applicant use tobacco?
Yes No

The reason I am requesting a quote.

I have already read the QuickQuote.
Yes No

I have already read the Guide.
Yes No

I am mostly interested in : A, B, or C
A: Traditional Long Term Care Insurance Only 1
How much have you budgeted for a monthly premium? per person

How much of a daily benefit do you want to receive?

blankHow long do you want the benefits for?

B: Single Premium Universal Life Insur. with LTC Benefits 2
OR
C: Single Premium Fixed Annuity with LTC Benefits 3
I currently have: (select all you have for source of funding)
Annuity CD Money Market 401k IRA Savings Other

Send me a quote with a long term care rider amount of :


City and State of residence:
(required - quotes are state specific)

E-mail me the quote to :
(required to send quote)		 (email address)

I currently have a long term care insurance policy:
Yes No

If the quote is appropriate and affordable I will apply by mail.
Yes No

I will want free phone support when I apply.
Yes No

Also send information on small business and corporate plans.
Yes No

When do you want to start?

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

How did you find this website?

Are you an agent or licensed to sell insurance (active or inactive)? (required)


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