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> Insurance Quotes > LTC Quote Request
LTC Quote Request
Long Term Care (LTC) Quote Proposal Form:
Please fill in the information below:
Customer Name (
required
):
First
MI
Last
Email (
required
) :
Date of Birth:
/
/
Sex:
-Select-
Male
Female
Height & Weight:
Height
<4' 6"
4' 7"
4' 8"
4' 9"
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7' OR >
&
Weight
<75 lbs.
75-80 lbs.
85-90 lbs.
95-100 lbs.
100-105 lbs.
105-110 lbs.
110-115 lbs.
115-120 lbs.
120-125 lbs.
125-130 lbs.
130-135 lbs.
135-140 lbs.
140-145 lbs.
145-150 lbs.
150-155 lbs.
155-160 lbs.
160-165 lbs.
165-170 lbs.
170-175 lbs.
175-180 lbs.
180-185 lbs.
185-190 lbs.
190-195 lbs.
195-200 lbs.
200-205 lbs.
205-210 lbs.
210-215 lbs.
215-220 lbs.
220-225 lbs.
225-230 lbs.
235-240 lbs.
240-245 lbs.
245-250 lbs.
250-255 lbs.
255-260 lbs.
260-265 lbs.
265-270 lbs.
270-275 lbs.
275-280 lbs.
280-285 lbs.
285-290 lbs.
290-295 lbs.
295-300 lbs.
300-305 lbs.
305-310 lbs.
310-315 lbs.
315-320 lbs.
320-325 lbs.
325-330 lbs.
330-335 lbs.
335-340 lbs.
340-345 lbs.
345-350 lbs.
>350 lbs
Tobacco Use:
Never
No
Yes
Cigarettes
Cigar
Pipe
Smokeless
-Select-
Marital Status :
-Select-
single
married
State of Primary Residence :
Alabama
Alaska
Arizona
Arkansas
California
Coloado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebaska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Daily Nursing Home Benefit desired :
$
100
110
120
130
140
150
160
170
180
190
200
Benefit Period :
Lifetime (recommended)
12 years
10 years
8 years
6 years
5 years
4 years
3 years
2 years
720 Days
1 year
Rate Class :
Show All
Standard
Preferred
Select
Class 2
Waiting Period Before Benefits Begin :
0 Days
20 Days
30 Days
50 Days
60 Days
90 Days
100 Days
180 Days
365 Days
730 Days
Include Compound Inflation Protection?:
Yes (recommended)
No
Include Home Health Care Coverage?:
Yes
No
Include Spouse Discount? :
Yes
No
(Spouse discount applies for most companies when both husband and wife apply for coverage at the same time)
Optional Spouse Information
Name :
First
MI
Last
Date of Birth:
/
/
Height & Weight:
Height
<4' 6"
4' 7"
4' 8"
4' 9"
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7' OR >
&
Weight
<75 lbs.
75-80 lbs.
85-90 lbs.
95-100 lbs.
100-105 lbs.
105-110 lbs.
110-115 lbs.
115-120 lbs.
120-125 lbs.
125-130 lbs.
130-135 lbs.
135-140 lbs.
140-145 lbs.
145-150 lbs.
150-155 lbs.
155-160 lbs.
160-165 lbs.
165-170 lbs.
170-175 lbs.
175-180 lbs.
180-185 lbs.
185-190 lbs.
190-195 lbs.
195-200 lbs.
200-205 lbs.
205-210 lbs.
210-215 lbs.
215-220 lbs.
220-225 lbs.
225-230 lbs.
235-240 lbs.
240-245 lbs.
245-250 lbs.
250-255 lbs.
255-260 lbs.
260-265 lbs.
265-270 lbs.
270-275 lbs.
275-280 lbs.
280-285 lbs.
285-290 lbs.
290-295 lbs.
295-300 lbs.
300-305 lbs.
305-310 lbs.
310-315 lbs.
315-320 lbs.
320-325 lbs.
325-330 lbs.
330-335 lbs.
335-340 lbs.
340-345 lbs.
345-350 lbs.
>350 lbs
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.
Contact Independent Planner LLC. today at (716).634.8705 - (800).279.0298 - (716).634.1636 (fax)
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