LTC inquiry form

You will receive a confidential response to your inquiry upon review of the following information:

Name (the person completing this form):

Name of person for whom you are interested in providing long term care protection:

Your relationship to this person:

This person's [appx.] age:

This person's [appx.] height:

This person's [appx.] weight:

Does this person smoke?

Yes No

What medications is this person currently taking?

Are you interested in a policy which provides for nursing home care?

Yes No

Are you interested in a policy which provides for care in the person's own home?

Yes No

Is a family member potentially available to provide in-home care if a policy could pay them for these services?

Yes No

Please tell us candidly about the general state of this person's health and what past or current medical conditions they have:

Your daytime phone number including area code:

Your e-mail address:

Mailing address:

City, State:

ZIP:

Please provide additional questions/information here:

(Remember, there is NO obligation to purchase from us! We simply welcome the opportunity to provide you with customized quotes that will best suit your situation....)

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