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Long Term Quote Request
A few minutes is all it takes to get accurate quotes!
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Where do you live?
*
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York - Not Available
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
What is your gender?
*
Female
Male
When were you born?
*
MM
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DD
1
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YYYY
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Layout
First Name
Last Name
Email
*
Phone
Do you use tobacco/nicotine products?
-Select-
Never
Former Tobacco User
Cigarettes
Cigars
Chewing Tobacco
E-cigarettes or Vape
Marijuana
How often do you smoke cigars?
Celebratory/Special Occasions
One Per Month
One Per Week
Daily Smoker
Please indicate type of tobacco and date you quit tobacco use.
What Type of Coverage Would You Like to See? (Select All That Apply)
Traditional Long Term Care Policy
Hybrid - Provides Life Insurance with Benefits for Long Term Care
Term Life with Living Benefits Riders
Traditional - provides long term care only. If you die without needing long term care, you get nothing. Hybrid - Provides life insurance if you die, and long term care if you need benefits. Term Life - Is a term life insurance policy providing accelerated benefits for chronic and/or critical illnesesses.
Is Your Spouse/Partner Applying for Coverage?
Yes
No
Some companies offer additional discounts for spouses/partners.
Daily Benefit You Would Like for Care
$100
$200
$300
$400
$500
Not Sure Yet
We can help you with average daily costs in your area. If considering a hybrid, we can show you how much benftit that policy will provide.
Elimination Period Before Benefits Begin:
Zero Day Elimination Period
30 Days
60 Days
90 Days
180 Days
365 Days
The elimination period is the amount of time that passes before your benefits begin.
Inflation Protection
No Inflation Protection
Simple Inflation Protection
Compound Inflation Protection
Most policies offer choices for inflation protection from nothing, simple inflation of 3% - 5% or compound inflation of 3%-5%. The illustrations will show you what each looks like.
Premium Payments
Pay All Years
Pay over 10 Years
Pay to Age 65
Single Lumpsum Payment
How tall are you?
Select
4'-11"
5'-0"
5'-1"
5'-2"
5'-3"
5'-4"
5'-5"
5'-6"
5'-7"
5'-8"
5'-9"
5'-10"
5'-11"
6'-0"
6'-1"
6'-2"
6'-3"
6'-4"
6'-5"
6'-6"
6'-7"
6'-8"
6'-9"
6'-10"
6'-11"
7'-0"
How much do you weigh?
Select
95
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400
Greater than 400
Is there any family history of parents or siblings having heart disease, cancer, or diabetes before the age of 70?
No
Yes
Have you ever been diagnosed with or treated for:
Brain - MS, Stroke, Epilepsy
Cancer History
Drug and/or Alcohol Abuse
Endocrine Disorders
Gastrointestinal Problems
Heart Conditions
High Blood Pressure
HIV Positive
Immune System Disorders
Mental or Nervous Disorder
Respiratory Problems
Other Health History
What type of heart condition do you have?
Abdominal Aortic Aneurysm
Coronary Calcium Score
Abnormal EKG
Coronary Artery Disease
Angina
Heart Attack
Angioplasty
Heart Murmur
Aortic Stenosis
Heart Stents
Atrial Fibrillation
Heart Valve Surgery
Bundle Branch Blocks
NT-proBNP
Bypass Surgery
Pacemaker
Other Heart Condition
What type of cancer were you diagnosed with?
Bladder
Prostate
Breast
Skin
Cervical
Testicular
Colon
Throat
Kidney
Thyroid
Lymphoma
Other Cancer
What type of gastrointestinal condition were you diagnosed with?
Crohn's Disease
Elevated Liver Functions
Hepatitis
Ulcerative Colitis
Other Gastrointestinal
What type of endocrine disorder do you have?
Addison's Disease
Diabetes
Metabolic Syndrome
Proteinuria
Thyroid Disease
Other Endocrine
What type of respiratory condition do you have?
Asthma
Sleep Apnea
COPD
What mental health condition were you diagnosed with?
Anxiety
Bipolar Disorder
Depression
Eating Disorders
Obsessive Compulsive Disorder
PTSD
Other Mental Health
Do you take any medications?
Yes
No
What medications do you take?
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