Long-Term Care Insurance Quote Form

Ensure the protection of your life’s work and the well-being of your loved ones. A comprehensive plan for the future includes identifying potential vulnerabilities such as not having enough life and disability insurance and long-term care coverage.

  • 1. Applicant information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 2. Health information

    List medical conditions treated in the last 5 years and surgery performed or scheduled in last 5 years.
    If you require more space to write, please utilize section 4.









  • 3. Long-term care insurance plan (for initial quoting purposes only; see definitions below*)​

  • 4. Additional comments

  • 5. *Definitions: Long-term care policy provision definitions

  • Benefit

    • Daily: Maximum amount per day the policy will pay in benefits, including the inflation benefit.
    • Monthly: Maximum amount per month the policy will pay in benefits. Particularly meaningful for home health care when services and costs vary from day to day. Allows for more flexibility and access to benefits.
      • Method 1-Daily benefit selected is multiplied by the exact number of days in any specific month resulting in a monthly pool of money/benefits that is available.
      • Method 2-A specific monthly benefit amount is selected outright.

    Benefit Period In Years

    • Number of years the insured wants to receive benefits.

    Elimination Period In Days

    • A deductible in days rather than dollars. The number of days the insured wants to receive services before the policy starts paying benefits?

    Benefit Increase

    • None: The benefit amount remains the same throughout the life of the policy.
    • GPO: Guaranteed Purchase Option provides the insured with periodic opportunities to purchase additional daily benefits at attained-age rates.
    • 5% Simple: Automatically increases the original benefit by 5% every year.
    • 3% or 5% Compound: Selected inflation amount is added to the daily benefit and is compounded annually.

    Option Riders

    • Return of Premium: Upon the death of the insured, all or a portion of the paid premiums are returned to the insured’s beneficiary, less any benefit amounts that were paid out.
    • Waiver of HHC EP: Home Health Care Waiver. The selected Elimination Period (EP) still applies for nursing home expenses but if the insured is able to stay at home and receive care there the insurance company will ignore the elimination period and start paying benefits immediately.
    • Restoration of Benefits: The benefits in a policy will be restored if an insured gets better and goes without care for a specified period of time, usually six months, and does not completely exhaust their benefit amount.
    • Shared Care: Allows a married couple to access benefits under the same policy or from the spouse’s policy provided that:
      • Both spouses have identical coverage from the same carrier, and
      • One spouse has exhausted the benefits under his/her own policy.
    • Non-Forfeiture: If the insured cancels the policy or coverage lapses they will receive some of the benefits they have paid for

This is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form. Note that any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form and/or in communications with us. All coverage is subject to the terms, conditions and exclusions of the actual policy issued.