Request A Quote
In order to create your own Long Term Care (LTC) plan, you need to answer the questionnaire below and submit it.
FILL OUT THE FORM TO RECEIVE A QUOTE
Policy Format:
Joint
Single
Client #1:
DOB:
Smoker?
No
Yes
Client #2:
DOB:
Smoker?
No
Yes
CLIENT DETAILS
Client #1
Current Medications:
(name & purpose)
Sugeries/Hospitalization:
(past 5 years)
Client #2
Current Medications
:
(name & purpose)
Sugeries/Hospitalization:
(past 5 years)
PLAN DETAILS
Daily Benefit:
$40 - $500/per day benefit.
per day
Waiting Period:
30 Days
60 Days
90 Days
(the amount you cover before benefits)
Payment Lengths:
2 years
3 years
4 years
5 years
6 years
10 years
Life
Inflation Protection:
None
Simple
Compounded
CONTACT INFORMATION
Preferred Contact:
Phone
Email
Fax
Phone #:
Fax #:
E-Mail:
Message:
