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Individual Long-term Care Insurance

In order to obtain individual long-term care insurance quotes, please complete the information below. Quotes available to individuals located in the state of Massachusetts.

Request Personalized Quote

Please fill out completely. Quotes provided are based on information provided. Final rates are determined by the Insurance Carrier once the application has been submitted with any other requirements and been reviewed by an underwriting department.

*denotes required information.
Name*:
Address*:
City*:
State*: Zip*: 
Contact E-Mail*:
Phone Number*:  ext:
Fax Number :
Gender*:
Date of Birth*: / /  (format: MM/DD/YYYY)
Height*:     Weight*:
Have you used tobacco in the last five years?*     No      Yes

Do you have symptoms of, or within the last 10 years, have you received medical advice, diagnosis or treatment or consulted with a member of the medical profession for any of the following conditions? heart disease, coronary artery disease, circulatory disorders, high blood pressure, leukemia, lymphoma, cancer, paralysis, stroke, TIA, bowel disorders, bladder disorders, prostate disorder, kidney disorder, depression, alcoholism, drug addiction, osteoporosis, arthritis, disorders of the reproductive organs, respiratory disorder, shortness of breath, fainting spells, injury due to falls or imbalance, seizure, tremor, diabetes, liver disorder.*

 No   Yes

If so, please detail each condition separately below, specifying the date of onset, medications used to treat the condition, and details on the current status of the condition.* (required if yes)


Within the last 10 years have you ever had an application for long-term care, life, or health insurance declined or any such policy modified?    No   Yes

Have you ever received home health care or been confined to a nursing home or rehabilitation facility?    No   Yes





Select type of plan options you are interested in:

Inflation Option:
Elimination Period:
Nursing Home Benefit Period:
Nursing Home Daily Benefit:
Home Health Care Benefit Period:
Home Health Care Daily Benefit:


Payment terms desired  :

When would you like to apply:

Additional comments:


  

195 Washington Street á North Easton á MA á 02356 á 508-230-SAVE/7283

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