Information Request Form
Please answer the following questions to receive a complimentary consultation regarding your long term care insurance needs. All information is kept strictly confidential. * denotes a required field.
Name*:
Date of Birth:
Spouse’s Name:
 Date of Birth:
E-mail Address*:
Street Address:  
City:   State:   Zip:  
Contact Phone Number:   Best time to call: Morning Afternoon Evening
How did you find this website?
What is your main reason for seeking coverage for long-term care?
Do you currently own a long-term care policy that you would like to compare with other plans available? Yes No
If yes, List Carrier and Year purchased
Health Information
In the past 5 years, have you or your spouse used tobacco products including cigarettes, pipe, cigar or chewing tobacco?
You: Yes No
Your Spouse : Yes No
During the past 10 years, have you been confined to a hospital, nursing home, received home care or diagnosed or treated for any serious condition? If so, please describe.
You: Yes No
Your Spouse: Yes No
Please list all medications you are currently taking and what they are for.
You:
Your Spouse:
   
Please tell us how you heard about our website:
Other:
Comments or Questions
Please list any additional comments or questions you have.