Falls Insurance Long Term Care Quote

* Required Information

About You

* Your First Name

* Last Name

* Email

* Email Verification

* Street Address

* City

Select State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming *

* County

* Zip

* Phone (Day)

Phone (Evening)

Fax

Company Name (if applicable)

Your Long Term Care Insurance Information

Do you currently have Long Term Care Insurance?
Yes No

If YES, when does your current policy expire?

If YES, who are you currently insured with?

If YES, what is the policy number?

Are you a Male Female

/ / What is your Birth Date (mm/dd/yyyy)

Your Social Security Number

Your Height

Your Weight

Your Occupation

What deductible (waiting) period would you prefer? 0 days 30 days 60 days 90 days 180 days 365 days Deductible Waiting period?

Benefit Period? 2 years 3 years unlimited Benefit period?

Maximum Daily Benefit? $100 a day $120 a day $250 a day Maximum daily benefit?

When did you last use any tobacco products? Never Currently 1 year ago 2 - 4 years ago 5 or more years ago Tabacco?

Do you want an inflationary rider?
with 5% Without

To your knowledge, is there any family history (grandparents, parents, or siblings) of cardiovascular disease before the age 60?
Yes No

.If

Optional coverage (check the ones you may want)

Health Insurance
Prescription Card
Supplemental Accident
Maternity
Long Term Care
Senior Care
Disability Insurance
Life Insurance

.

Spouse? Include in Quote Don't Include

Spouse is a Male Female

/ / Spouse's Birth Date (mm/dd/yyyy)

Spouse's Social Security Number

Spouse's Height

Spouse's Weight

Spouse's Occupation

When did your spouse last use tobacco products? Never Currently 1 year ago 2 - 4 years ago 5 or more years ago Tabacco?

.

Details

When would you like to be contacted?
Morning
Afternoon
Evening
Any Time

Any Comments / Questions?

Want to receive relevant information from The Falls Insurance Center Inc?
Yes No

.What info shall we send to you?