*   Who are you requesting this quote for: Select Client Myself/Ourselves Parent Aunt/Uncle Sibling Friend Other Relation

*   E-mail address:

*   First Name: , of the person to be protected.
*  Last Name:
*  Date of Birth: January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day Year 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984
*  Health Conditions: Select Excellent Average Poor

*  Use of tobacco products within the past three years? Yes No

Please fill out this area ONLY if there is an insuree spouse / companion / partner.

First Name:
Last Name:
Date of Birth: January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day Year 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984
Health Conditions: Select Excellent Average Poor

Use of tobacco products within the past three years? Yes No

*   Contact Information:

*  Street Address:
*  City:
*  State: NY ----- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code:
*  Phone:
Fax:
Best time to call:
Preferred Contact: Select Phone & E-mail In-person

*  To better meet your needs please answer these few additional questions:

Would you be willing to answer health questions to an insurance agent? Yes No

If Long-Term Care Insurance meets your expectations, and fits in your budget; do you plan on enrolling in the next 60 days? Yes No

Do you currently own a Long-Term Care Insurance Policy? Yes No

*  What is the reason for you seeking LTC Coverage? Select Remain Independent Protect Assets Protect Spouse Choice of Care Not to be Wiped Out Stay off Welfare Avoid Being a Burden Other

If you have chosen other, please provide your reason for seeking LTC coverage:

How did you find us? Select Google MSN Lycos AltaVista Yahoo LookSmart InfoSpace Other Received Postcard

Additional Comments:

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