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We recommend you first read QuickQuote which will give you an idea of the cost of long term care insurance.

We represent all the major insurance carriers for long term care insurance, life insurance and annuties with LTC riders. We DO NOT share or sell your information. We are not a "lead" company. You will not be getting multiple phone calls from different agents.

The premiums are the same if you buy your insurance through us, another agent or agency, or directly from a company or organization.

The quotes based on current rates from the top companies as of

An advisor will contact you to answer questions you may have. We can also arrange for a local advisor meet with you.

Fill out this form only if you are interested in insuring through us in the next 60 days because the rates, your age, or your health can change (it happens all the time) and the quote will no longer be accurate.

If you are simply curious about the price you can read the QuickQuote instead of requesting a custom quote.

The information you provide to us with this form will help us determine your insurability and health rating. The more information you provide in the form the more accurate quote we can provide.

We respect your privacy, we do not share this information.


I am interested in : A, B, or C

A: Long Term Care Insurance Quote (LTC insurance information)
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?

Funding Life Insurance or Annuity: Non-Qualified vs Qualified Money
Non-Qualified: Taxes have been paid. Cash, stocks, bonds, savings, CD's, money market. Not available in NY, CT, NJ, NH.

Qualified: employer provided or an individual retirement plan. Usually 401ks, IRAs, retirement plans, tax deferred annuities. If over age 59 1/2 can use up to 60% of all qualified money . Not available in NY, CT, NJ, NH.


B: Life Insurance with LTC Rider (Life/LTC information)
Life/LTC policy amount desired:
Select source of funding:
Current Whole Life or Universal Life policy (not Term life insurance) Current policy cash value is
If using Qualified (IRA/401k) $

 

C: Annuity with LTC Rider (Annuity/LTC information)

Annuity LTC rider desired amount :
 
Select source of funding:
Current Annuity Current annuity value is
If using Qualified (IRA/401k) $











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Name or initials:

Age
Weight:
Lbs.
Height: (ft-in ex. 5-8)
Spouse or Other:

Age
Weight:
Lbs.
Height: (ft-in ex. 5-8)
Marital Status (possible discount even if only 1 insures)
Does either applicant take prescription medications?
Y N Must describe below.
Must specify medications
(a) Which applicant (b) Name of medication (c) What taken for  (d) Any current or past major health issues for the last 10 years.
Does either applicant use tobacco last 5 years?
Self Other Applicant

The reason I am requesting a quote is
I have already read the QuickQuote and the premium is affordable.
Y N

Do you currently have a long term care insurance policy? (required)
Y N
Are you an agent or licensed to sell insurance (active or inactive)? (required)
Y N
Are you working with anyone now about long term care insurance? (required)
Y N

I prefer to apply by: (required)
Mail/FedEx In-Person
When do you want to apply? (required)

City and State of residence:
(required - quotes are state specific)
E-mail me the quote to :
(required to send quote)
(email address)
Phone: (entry required)
*an advisor will explain the quote and answer any questions
Best days to contact you:
M-F Sat Sun
Best times to contact you:
AM — PM

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

 

 

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