Service My Insurance" Account Request FormOne Simple Form

On-Line Long Term Care
Insurance Quote Form

One Simple Form - takes only 2-3 Minutes!

Your Personal Data

Your Name*

First NameLast Name

Street Address

Street Address Line 2

CityState (Must be Georgia)

Postal / Zip Code

E-mail*

Confirmation Email

Phone Number*

Area CodePhone Number

Fax Number

Area CodePhone Number

Marital Status:

SingleMarried

Are You Looking For Spouse Coverage?

YesNo

Health Ins. Currently? (If yes, list carrier, and # of years continuous. If none, type N/C)

UNDERWRITING INFORMATION

Insured Name:

Birthdate:

Height:

Weight:

Occupation:

Sex (M/F):

Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!

Do You use tobacco?

YesNo

Describe usage (cigar, cigarettes, etc.)

Any Pre-existing Health Conditions? (If yes, descibe in detail, and to which of the insured persons they apply.)

Any Covered Persons Currently Taking Medication of Any Kind? (If yes, descibe in detail, and to which of the insured persons they apply.)

COVERAGE INFORMATION

How Long Do You Need Coverage For? (1 Year, 5 Years, Lifetime, etc.)

What Daily Benefit Amount Needed? (In Dollars $)

What Waiting Period Do You Want? (30 days, 60 days, 90 days, etc.):

Any special coverages needed? (Such as Home Health Care Cov., Compound Inflation Rider, etc.)

Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:

Send my quotation via:

FaxE-MailRegular MailPlease Call Me!

Thank you for filling out this form completely!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I agree. Please send me my long term care quote now!

YES

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