(407) 290-8414 rob@ltcresearch.com

Long Term Care Insurance Quote Request Form

This is not an application for insurance. This secured form is only used to evaluate your potential eligibility for Long Term Care Insurance and to provide you with an accurate quote. Each question has a bearing on determining both your eligibility and the premium rate so please answer each question to the best of your knowledge.

Upon submission of this form you will receive exclusive access to the acclaimed television special “Blindsided.”

Fields marked with an * are required

NAME OF PERSON COMPLETING THIS FORM
Who are you researching this information for? *

FIRST PERSON
Are you married? *
Have you smoked cigarettes in the past 3 years? *
Have you been hospitalized overnight in the past 5 years? *
Are you taking any medications? *

Name of medication

Reason

Dosage

Approx. how long taking?
Do you have any surgeries pending? *
Have you ever had any of the following medical conditions?
Memory Issues *
Cancer *
Stroke *
Sleep Apnea *
Heart Problems *
Back surgeries *
Osteoporosis *
Parkinson's *
Diabetes *
Are you on any kind of disability? *
Do you have a handicap sticker on your car? *
Do you use any type of support devices such as canes, crutches, walkers, wheelchairs etc.? *
Are you currently going through any type of physical therapy? *
Do you currently own a long term care insurance policy? *
Have you ever been declined for long term care insurance? *