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Long Term Care Quotation Request Form

Who should care about Long-Term Care?

Anyone who has assets or income to protect . . . anyone who is age 50 or older . . . and anyone who does not want to be dependent on others should care about long-term care.

Statistics tell us that more than half of all women and a third of all men who survive to age 65 will spend time in a nursing home before they die. Medicare does not cover this expense, nor does an ordinary health insurance policy. So unless you’ve purchased long-term care insurance, it’s possible the remainder of your life’s savings will quickly disappear. Take a look at the latest statistics related to the cost of long-term care.

The average cost for a private room in a nursing home is $203 per day ($74,000 per year).
The average stay of a nursing home resident is 2-1/2 years (apx. $200,000).
The average cost of a home-health care aide is $20 per hour.

We would be happy to craft a policy for you that will meet your future needs and fit comfortably into your budget. Would you like to get started? Simply fill out the information below and we will provide you with a long-term care quotation.

*required fields

Personal Information

*Name: Last, First & Middle Initial
*Address:
City: State: Zip:
*Home Phone: Best Time To Call:
Work Phone: Best Time To Call:
Fax:
*E-Mail:
Are you employed? yes no
Do you own your own company? yes no
Would you like to include coverage for your spouse? yes no

How would you like to be contacted?

[E-Mail: ] [Phone: ] [Fax: ]

Long Term Care Information

	Yourself	Your Spouse
Date of Birth:
Gender:	Male Female	Male Female
Height:
Weight:
Do you currently own a LTC Policy?	yes no	yes no
Do you use tobacco products?	yes no	yes no

In the past 5 yeas, have you been confined to a hospital? yes no
In the past 5 years, have you been confined to a nursing home? yes no

Do you take any prescription medications? Yes No
Please list the medication you take.

Do you have any health conditions such as diabetes, cardiovascular disease, cancer, other?

Will existing coverage be replaced? Yes No

Have you ever had insurance declined or rated? Yes No

The Plan

What is the daily benefit you desire?
How long do you want coverage?
When would you like benefits to begin?
Would you like inflation protection? yes no
Do you want coverage for home health care? yes no

Underwriting Center
10335 N. Port Washington Rd., Ste. 200, Mequon, Wisconsin 53092-5763
Telephone: 262-478-1000 Facsimile: 262-478-1001 Toll Free: 800-845-4145