Long Term Care

» Name:

Address:

Please leave this field empty.

City:

State:
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip:

» Phone:

» Your Email:

M/F:

MaleFemale

Age:

Height:

Weight:

What daily benefit would you like your long-term care policy to provide?
$50$60$70$80$90$100$110$120$130$140$150$160$170$180$190$200$210$220$230$240$250$260$270$280$290$300$350$400$450$500

If you need long-term care, what's your desired waiting period before benefits begin?
0 - 30 Days31 - 100 Days101 - 365 Days

If you need long-term care, how long do you want to be eligible for benefits?
Lifetime3 years or more12 to 35 months

Do you want your policy to include home-health care coverage?
YesNo

Do you want your policy to have the option to increase with inflation?
YesNo

Briefly describe any medical events in the past 10 years that have required hospitalization or surgery:

Are you a tobacco user?

YesNo

How would you describe your health?

ExcellentVery GoodGoodPoor

Any additional information to consider as we process your request?

Is your spouse also applying for Long-Term Care?

YesNo

Spouse Name:

Spouse Address:

Spouse City:

Spouse State:

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Spouse Zip:

Spouse Phone:

Spouse Email Address:

Spouse M/F:

MaleFemale

Spouse Age:

Spouse Height:

Spouse Weight:

What daily benefit would your spouse like the long-term policy to provide?

$50$60$70$80$90$100$110$120$130$140$150$160$170$180$190$200$210$220$230$240$250$260$270$280$290$300$350$400$450$500

If your spouse needs long-term care, what's their desired waiting period before benefits begin again?

0 - 30 Days31 - 100 Days101 - 365 Days

If your spouse needs long-term care, how long do they want to be eligible for benefits?

Lifetime3 years or more12 to 35 months

Does your spouse want their policy to include home-health care coverage?

YesNo

Does your spouse want their policy to have the option to increase with inflation?

YesNo

Briefly describe any medical events for your spouse in the past 10 years that have required hospitalization or surgery

Is your spouse a tobacco user?
YesNo

How would you describe your spouse's health?
ExcellentVery GoodGoodPoor

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