About Us Forms Life & Health Employee Benefits Insurance 101 Contact

Group Long-Term Care Insurance Quote Request

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Legal Name of Business:
Contact Name:
Address:
City:
State:	Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
E-mail Address:

Business Information
Type of Business:
Number of Employees to be Insured:
Do you currently offer long-term care insurance to employees?	Yes No
Want long-term care insurance coverage for:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group LTC Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:	Premium Amt: $
Years Insured:
Please give a brief description of your current Group LTC plan:

Coverage Options
Type of Coverage:	New Coverage Additional Coverage Replacement
Waiting Period:
Daily Benefit Amount:
Benefit Period:
Inflation Protection:
Do you want your policy to include home-health care coverage?	Yes No

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Salary	Sex	Dependent Status
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
			Male Fem
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or e-mail an additional listing.

Additional Comments or Questions

Please click the "Submit Quote" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.