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Home
International Insurance
Life Insurance
Life Basics
Permanent Life
Term Life
Calculate Your Needs
Life Insurance Quote
Term Life Insurance Glossary
Long Term Care
Long Term Care
Understanding Long Term Care
Disability Income
Medicare
Medicare Supplement Information
Medicare Part D
Medicare 2022 Basic Information
Medicare Insurance Glossary
Medicare & You
Contact
Long Term Care Quote
Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
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Indicates required field
Name
*
First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone
*
Alternate Phone
*
Date of Birth
*
Gender
*
Male
Female
Underwriting Information
Have you received disability compensation?
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Yes
No
Do you smoke or chew tobacco?
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Yes
No
Have you used any illegal narcotics?
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Yes
No
Is your health impaired in any way?
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Yes
No
Are you taking medication?
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Yes
No
Do you have high blood pressure?
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Yes
No
Do you have asthma, emphysema or respiratory problems?
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Yes
No
Do you have cancer or other tumors?
*
Yes
No
Do you have diabetes?
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Yes
No
Have you ever been declined life,health or disability insurance?
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Yes
No
Are you a U.S. citizen?
*
Yes
No
Tobacco Usage?
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Yes
No
Tobacco Use
*
None Ever
None in the past 5 years
None in the past 3 years
None in the past 1 year
Pipes and Cigars only
Cigarette
Nicotine Patches and Gum
Coverage Information
*
How long would you like to receive benefits
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1 year
2 years
3 years
4 years
5 years
Do you currently have LTC insurance?
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Yes
No
If yes, what type?
*
Questions or Comments
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Best Time To Contact You
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Morning
Afternoon
Evening
Anytime
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In the number 63829, what is the 1st digit?
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