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

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 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 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.

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 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 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

Contact Information:

Street:
City:
State: Select 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:
E-mail address:
Daytime Phone:
Evening Phone:
Fax:
Best time to call:
Preferred Contact: Select Phone & E-mail In-person

If you could just answer a these few questions below, to ensure you quality service:

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:

Additional Comments: