Your name:
Your home address:
Your phone number:
Date Of Birth:
Your email address:
Male:
Female:
Your Height:
Smoker?:
Your Weight:
Diabetic?:
Insulin Dependant?:
Use A Cane?:
Use A Walker?:
Use A Wheel Chair?:
Any Other Equipment?:
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??:
nursing home?:
had home care?:
had long-term care?:
Please describe your
particular health
problems:
received
rehabilitation?:
currently own a
long-term care policy?:
Benefit period desired
Prescribed
medications:
Daily Benefit - nursing
home coverage
Daily benefit - home &
community care
Inflation
protection/cost-of
living adjustment
How long can you
afford to pay for a stay
in a nursing home out
of your savings
without having to sell
any of your assets
such as your home,
property, cars,
investments, etc?
Please let us know
the best time to call
and discuss your
quote.
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.
RJ Insurance & Travel Services
Long Term Care Quote