Fill out this form in order to receive long term
care insurance coverage quotes. We forward
your information to licensed long term care
insurance agent specialists who will contact
you in a timely manner, usually within a few
hours, with a quote(s) by the method you
request: email or phone.
Our services are 100% free to you. We also
require that insurance agents do not share
your personal information to non-insurance
related sources.
Long Term Care Insurance Quote
       How many quotes for Long Term Care insurance
       coverage do you want to receive?


Contact Person (if different than Applicant)
Full Name:  
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
Contact me:


Applicant: Full Name:   
Home Address:
City:   State:   Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
Contact me:
Date of Birth:  (mm/dd/yyyy)
Gender:   Height:  ft. 
Weight:    Do you smoke?
Currently Insured?   Current Premium:$  per month

Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please provide the necessary information below:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:


                                         Is Spouse to be insured?
Spouse: Full Name:   
Spouse Date of Birth:  (mm/dd/yyyy)
Spouse Gender:   Spouse Height:  ft.   inches   Spouse Weight:
Does your Spouse smoke?
Is Spouse married to the Main Applicant?

Is spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please provide the necessary information below:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:


Coverage requested for?
Daily Benefit Amount $:
Benefit Period:
Elimination Period:
Payment Mode:


Do you own or rent your primary residence?
What amount do your current assets total? 

Additional Information or Comments



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Long Term Care Insurance Coverage Information
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Health Insurance
Your one stop source for Long Term Care Insurance quotes.
We appreciate having the opportunity to
assist you with receiving long term care
insurance coverage quotes.
Information received from this long term care insurance quote form sent to HealthInsuranceQuoter.com will be
forwarded to insurance agents licensed to sell long term care insurance coverages in your state.
HealthInsuranceQuoter.com is not a licensed insurance agent and in no way intends to represent itself as such.
Quotes will be created by insurance agents based on the information you provide and HealthInsuranceQuoter.com
is not affiliated with, partnered, or owned by any of the insurance agencies that will provide quotes. The precise
coverage afforded is subject to meeting underwriting guidelines, and the terms, conditions and exclusions of the
policy as issued. By submitting this request you acknowledge that this is neither an offer to insure nor a guarantee
of insurance. Completion of this form does not entitle you to long term care insurance.
Long Term Care Insurance
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