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What would happen to your family if you were to need nursing home care?  With Long Term Care insurance you (or your parents) won't have to worry about paying for extended care.  Get a FREE no obligation Long Term Care Insurance Quote! You could save substantially for two minutes of your time

The short form below should be filled out as completely as possible in order to receive an accurate quote.

First Name

Last Name

Street Address



Zip Code





What is Your Daytime Number?


What is Your Evening Number?


Best Time to Contact You:

What is Your Email Address?



What is Your Gender

Birthday (mm/dd/yy)


Who is this quote for?

Name of parent (if different)
(otherwise, leave blank)


 feet inches







Are You married?

Yes     No 

Do You smoke?

Yes     No 

Are You a Diabetic?

Yes     No 

Are You Insulin-Dependent?

Yes     No 

Do You Use:

  wheel chair

If you use other medical
equipment, please describe
(otherwise, leave blank)

If you've required assistance with your everyday activities in the past 2 years please explain.
(otherwise, leave blank)

In the past 5 years, have you:

  been confined to a hospital/nursing home
  had home care
  had long term care
  recieved rehabilitation

If you have any particular health problems, please describe
(otherwise, leave blank)



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Long Term Care Basics
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