Thank you for considering Insurance Brokerage Service as your source for Long Term Care insurance. We represent several companies offering Long Term Care coverage and will be happy to search them to find the best rate for you. Listed below are a series of questions for you to answer so that we can determine the best quote for you. Please note that most companies offer a discount if both husband and wife are written in the same policy, so if you are married and wish coverage for your spouse, please complete the questions intended for your spouse. If coverage to be quoted is just for you, just leave blank the questions for your spouse. Please answer each question carefully then submit the entire form with the SEND button. We'll have a quote back to you within 24 hours.
Name: Address: City: State: Zip Code: Phone: FAX: E-Mail: Are you a male or a female? Male Female Male Your Date of Birth: What, if any, is your tobacco use (check all that apply)? No Tobacco Use Cigarettes Cigars Pipe Smokeless Tobacco Quote coverage for your spouse? Yes No Spouse's Date of Birth (if quoting for spouse): What, if any, is your spouse's tobacco use (check all that apply)? No Use Cigarettes Cigars Pipe Smokeless Tobacco What Elimination Period do you wish quoted? No Waiting Period 30 days 100 days What Benefit Period do you wish quoted? 1 year 2 years 3 years 4 years 5 years Lifetime What Daily Benefit (minimum $50) do you want quoted? How do you wish to make your payments? Continuous Payments Single Premium Paid Up In 10 Years Paid Up In 20 Years Paid Up At Age 65 Continuous Payments If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button. Thanks for considering Insurance Brokerage Service! Click here to return to our home page
What, if any, is your tobacco use (check all that apply)? No Tobacco Use Cigarettes Cigars Pipe Smokeless Tobacco Quote coverage for your spouse? Yes No Spouse's Date of Birth (if quoting for spouse): What, if any, is your spouse's tobacco use (check all that apply)? No Use Cigarettes Cigars Pipe Smokeless Tobacco What Elimination Period do you wish quoted? No Waiting Period 30 days 100 days What Benefit Period do you wish quoted? 1 year 2 years 3 years 4 years 5 years Lifetime What Daily Benefit (minimum $50) do you want quoted? How do you wish to make your payments? Continuous Payments Single Premium Paid Up In 10 Years Paid Up In 20 Years Paid Up At Age 65 Continuous Payments If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
Quote coverage for your spouse? Yes No Spouse's Date of Birth (if quoting for spouse): What, if any, is your spouse's tobacco use (check all that apply)? No Use Cigarettes Cigars Pipe Smokeless Tobacco What Elimination Period do you wish quoted? No Waiting Period 30 days 100 days What Benefit Period do you wish quoted? 1 year 2 years 3 years 4 years 5 years Lifetime What Daily Benefit (minimum $50) do you want quoted? How do you wish to make your payments? Continuous Payments Single Premium Paid Up In 10 Years Paid Up In 20 Years Paid Up At Age 65 Continuous Payments If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
Spouse's Date of Birth (if quoting for spouse):
What, if any, is your spouse's tobacco use (check all that apply)? No Use Cigarettes Cigars Pipe Smokeless Tobacco
What Elimination Period do you wish quoted? No Waiting Period 30 days 100 days What Benefit Period do you wish quoted? 1 year 2 years 3 years 4 years 5 years Lifetime What Daily Benefit (minimum $50) do you want quoted? How do you wish to make your payments? Continuous Payments Single Premium Paid Up In 10 Years Paid Up In 20 Years Paid Up At Age 65 Continuous Payments If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
What Benefit Period do you wish quoted? 1 year 2 years 3 years 4 years 5 years Lifetime What Daily Benefit (minimum $50) do you want quoted? How do you wish to make your payments? Continuous Payments Single Premium Paid Up In 10 Years Paid Up In 20 Years Paid Up At Age 65 Continuous Payments If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
What Daily Benefit (minimum $50) do you want quoted? How do you wish to make your payments? Continuous Payments Single Premium Paid Up In 10 Years Paid Up In 20 Years Paid Up At Age 65 Continuous Payments If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
How do you wish to make your payments? Continuous Payments Single Premium Paid Up In 10 Years Paid Up In 20 Years Paid Up At Age 65 Continuous Payments If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
If you have any questions or would like to provide us with additional information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
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