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Long Term Care Insurance Quote
 
First Name:
 
Last Name:
 
Daytime Telephone:
 
Evening Telephone:
 
Email:
 
Address:
 
City:
 
State:
 
Zip:
About You:
 
Your Birth Date
 
Your Gender
 Male Female
 
Your Height
Feet plus inches (example 5'6")
 
Your Weight
 
Are You Married?
 Yes No    
Spouse's Birth Date
Please Complete For Self/Spouse  
 
Self
Spouse
Do you smoke?
Yes No
Yes No
Are you diabetic?
Yes No
Yes No
Are you insulin dependent?
Yes No
Yes No
Do you use a cane?
Yes No
Yes No
Do you use a walker?
Yes No
Yes No
Do you use a wheel chair?
Yes No
Yes No
Do you use any other equipment?
Yes No
Yes No
If you have required assistance with everyday activities in the past 2 years, please explain
In the past 5 years have you:
Self
Spouse
been confined to a hospital?
Yes No
Yes No
nursing home?
Yes No
Yes No
had home care?
Yes No
Yes No
had long-term care?
Yes No
Yes No
received rehabilitation?
Yes No
Yes No
Please describe your particular health problems
Prescribed medications
Do you currently own a long-term care policy?
Yes No
Yes No
Long-Term Care Quote Selections
  Benefit period desired
(Average stay in a nursing facility is about 3 years) 
  Daily Benefit - nursing home coverage
  Daily benefit - home & community care
  How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?
The average cost per month is $5,000 which could be more depending on area of country 
  Inflation protection/cost-of living adjustment
Most needed for younger applicants 
Comments or Questions:
 
 
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Core Benefits
1107 Fair Oaks Ave. #522
South Pasadena, CA 91030

Toll Free: (888) 340-8885
 Phone: (626) 657-2210      fax: (323) 258-2558
 email: lawrence@core-benefits.com 


 

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