Get Long Term Care Insurance Quotes

Get Long Term Care Insurance Quotes

Please provide some basic information about you. We will search the marketplace for quotes based on your responses. Unless you ask for specific policy designs, we will prepare comparative quotes for both Traditional LTC and Hybrid Life/LTC policies, using a $5000 Monthly Benefit, 3 Year Benefit Period, and a 3% Compound Rider as a starting point. For couples, a Shared Care quote as well. This is a secure HIPAA Compliant Form.
Your Name

First NameLast Name
Birth Date

MonthDayYear
Preferred Email
example@example.com
Where is your primary residence? (Products may vary by State.)

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Please summarize any past or current health history that may be of interest. Include date of diagnosis, any details like T-Scores, Stage, etc., and planned follow-ups. Physical Therapy in the past six months, or recommended procedures, will have to be completed before an application can be submitted to the insurance company.
List all prescription medications currently taking, or have taken in the past five years. Include the reason taking, date started, and dosage.
Have you used any Tobacco or Cannabis / Marijuana products in the past five years?

NoYes. If yes, please call Ray to discuss before we provide quotes.
Spouse / Partner

If your spouse / partner is applying for coverage as well, please complete their information below. If they are NOT applying for coverage, please fill in only their name. We will then include the appropriate "one applying from a couple" discount to your quotes. Otherwise, you can jump to the last section.
Spouse/Partner Name

First NameLast Name
Birth Date

MonthDayYear
Preferred Email
example@example.com
Please summarize any past or current health history that may be of interest. Include date of diagnosis, any details like T-Scores, Stage, etc., and planned follow-ups. Physical Therapy in the past six months, or recommended procedures, will have to be completed before an application can be submitted to the insurance company.
List all prescription medications currently taking, or have taken in the past five years. Include the reason taking, date started, and dosage.
Have you used any Tobacco or Cannabis / Marijuana products in the past five years?

NoYes. If yes, please call Ray to discuss before we provide quotes.
Do you have any special requests? Comments? Or additional information we should know? If not, please use the "Submit" button below. You will receive an email confirmation of submission, without your responses displayed. Thank you!
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