Long-Term Care Insurance Quote

Long Term Care

LONG-TERM CARE QUOTE REQUEST
Please complete the following information if you would like to obtain a quote on Long-Term Care Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
	First
	Middle
What is your e-mail address?	e-mail
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Day
What is your telephone number?	Evening
What is your fax number?	Fax
What is your birth date?	Birth Date
What is your gender?	Gender	Male Female
What is your height?	Feet plus inches (example 5'8")
What is your weight?	Weight
Are you married?	Yes No	Spouse's Birth Date?
Fill in spouse if spouse is also applying
	Self	Spouse
Do you smoke?	Yes No	Yes No
Are you diabetic?	Yes No	Yes No
Are you insulin dependent?	Yes No	Yes No
Do you use a cane?	Yes No	Yes No
Do you use a walker?	Yes No	Yes No
Do you use a wheel chair?	Yes No	Yes No
Do you use any other equipment?	Yes No	Yes No
If you have required assistance with everyday activities in the past 2 years, please explain
In the past 5 years have you:
been confined to a hospital?	Yes No	Yes No
nursing home?	Yes No	Yes No
had home care?	Yes No	Yes No
had long-term care?	Yes No	Yes No
received rehabilitation?	Yes No	Yes No
Please describe your particular health problems
Prescribed medications
Do you currently own a long-term care policy?	Yes No	Yes No
Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or specify other:


	Partners In Health Care Appleton , WI 54914 Phone 866-779-0054 Fax 920-560-5545

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