The LTC Advisor

Quote Request

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Quote with Spouse/Partner or Single:
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Age or DOB:
Tobacco:
Height:
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List all hospital stays or serious illness or injury within the past ten years. Hepatitis, Heart Attack, Stroke, TIA, Diabetes, High Blood Pressure, etc.
If you have diabetes, how long have you had it and list medication, insulin, pills, etc.
Have you had any type of cancer or surgeries in the past five years?  If yes, explain type, treatment, and current prognosis
Do you use a cane, walker or oxygen, if so, explain
Medication/
Condition(1):
Medication/
Condition(2):
Medication/
Condition(3):
Medication/
Condition(4):
Medication/
Condition(5):
Spouse/Partner
Name
Age or DOB:
Tobacco:
Height:
Weight:
List all hospital stays or serious illness or injury within the past ten years. Hepatitis, Heart Attack, Stroke, TIA, Diabetes, High Blood Pressure, etc.
If you have diabetes, how long have you had it and list medication, insulin, pills, etc.
Have you had any type of cancer or surgeries in the past five years?  If yes, explain type, treatment, and current prognosis
Do you use a cane, walker or oxygen, if so, explain
Medication/
Condition(1):
Medication/
Condition(2):
Medication/
Condition(3):
Medication/
Condition(4):
Medication/
Condition(5):

Important Disclaimer: This is NOT an application for insurance. This is simply an information gathering tool by which we can generate accurate premium quotations and make recommendations regarding which insurance company you should apply with for long term care insurance. No insurance will go into effect until after you complete an actual application to an insurer, pay your first premium, and are approved by the insurer. Privacy Pledge: Your information is safe and secure - It will never be released to any other organization or mailing list - NO SPAM. You receive no unsolicited calls.

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