ESM Long-Term Care Insurance
Specializing In Senior Insurance/Medicare Supplements, Long-Term Care Insurance
(including the California Partnership for Long-Term Care Insurance) & other Senior Insurance Products
 
8300 Fair Oaks Blvd., Suite 202
Carmichael, CA 95608-1967
800-555-4023
916-646-6991
916-646-6992 (fax)
CA Ins Lic #: OB28602
E-mail:ltcsteve@sbcglobal.net

Our agency is licensed to quote and write insurance policies only in California. To find agents offering these coverages in all other states, please click the IQ.net logo.

 

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Long Term Care Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.

Name
E-Mail Address
Street
City, State, Zip
Daytime Phone
Night Phone
FAX
Personal Information
Sex
Date of Birth
Height
Weight
Do you smoke cigarettes
Occupation
Spouse Information
Sex
Date of Birth
Height
Weight
Do you smoke cigarettes
Occupation
Have either you ever had any indication of the following medical problems?
 
Heart disease
Cancer
HIV
Diabetes
Cholesterol
High Blood Pressure
 
Please explain YES answers above and any other medical problems either of you had in the past 10 years:
 
 
 
Long Term Care Information
 
Coverage type?
Coverage to begin on what day of nursing home confinement?
Amount of daily benefit desitred?
Length of Benefit Period ?
 
Available Options
Home & Community Care?
If yes, at what percentage of Nursing Facility Benefit?
Guaranteed Future Increases?
5% Cost of Living Adjustment?
10 year premium payment option?
Payment mode desired


This page and site has been developed and maintained by InsuranceQuote.Net
© Gordon K. Harden, Jr. 1996-97-98
mail to: gkh@InsuranceQuote.net
 
 
 
Page Created 12-22-98     Latest Revision 7-18-00