Long Term Care
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LONG TERM CARE QUOTE REQUEST
Please complete the following information if you would like to obtain a quote on Long Term Care Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. Answering the following questions on these pages will not result in a determination of your eligibility for coverage.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your e-mail address?
e-mail
What is your address?
Street
City
State
Zip
What is your telephone number?
Day
Evening
What is your fax number?
Fax
What is your birth date?
Birth Date
What is your gender?
Gender
Male Female
What is your height?
Feet plus inches (example 5'8")
What is your weight?
Weight
Are you married?
Yes No
Spouse's Birth Date?
Fill in spouse if spouse is also applying
 
Self
Spouse
Do you smoke?
Yes No
Yes No
Are you diabetic?
Yes No
Yes No
Are you insulin dependent?
Yes No
Yes No
Do you use a cane?
Yes No
Yes No
Do you use a walker?
Yes No
Yes No
Do you use a wheel chair?
Yes No
Yes No
Do you use any other equipment?
Yes No
Yes No
If you have required assistance with everyday activities in the past 2 years, please explain
In the past 5 years have you:
been confined to a hospital?
Yes No
Yes No
nursing home?
Yes No
Yes No
had home care?
Yes No
Yes No
had long-term care?
Yes No
Yes No
received rehabilitation?
Yes No
Yes No
Please describe your particular health problems
Prescribed medications
Do you currently own a long-term care policy?
Yes No
Yes No
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
Long Term Financial Solutions LLC

2202 N. West Shore Blvd, Suite 200 | Tampa, FL 33607
Phone 813-288-4646
Fax 813-288-4647
 
 
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