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Agency Name Here
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Agency Phone
Agency Fax
Agency E-mail:info@YourAgency.com

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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 (required)  
 E-Mail Address (required)  
 City, State, Zip  
 Daytime Phone  
 Night Phone  

 Personal Information
 Sex (required)  
 Date of Birth (required)  
 Do you smoke cigarettes (required)  
 Spouse Information
 Date of Birth  
 Do you smoke cigarettes  

 Have either of you ever had any indication of the following medical problems?
 Heart disease  
 High Blood Pressure  
 Please explain 'Yes' answers above and any medical problems either of you have had in the last 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?  
 0 year premium payment option?  
 Payment mode desired  


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mail to: gkh@InsuranceQuote.net

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