Info Request

Long Term Care Quote
Please fill in as much information as you feel comfortable with. The more information provided the more accurate the quote. After filling in the details click on the SUBMIT button.

Name:

Address:

Email Address:

Daytime Phone:

Evening Phone:

Your Birth Date:

Your Gender:

Male
Female

Your Height:

Your Weight:

Are You Married:

Yes
No

Spouses Birth Date:

Do You or Your Spouse Use Tobacco:

Myself
My Spouse
Both
Neither

Are You or Your Spouse Diabetic:

Myself
My Spouse
Both
Neither

Are You or Your Spouse Using Insulin:

Myself
My Spouse
Both
Neither

Do You or Your Spouse Use a Cane:

Myself
My Spouse
Both
Neither

Do You or Your Spouse Use a Walker:

Myself
My Spouse
Both
Neither

Do You or Your Spouse Use a Wheelchair:

Myself
My Spouse
Both
Neither

Do You or Your Spouse Use Oxygen:

Myself
My Spouse
Both
Neither

Do You or Your Spouse Use Any Other Equipment:

Myself
My Spouse
Both
Neither

What Equipment Do You Use:

In the Last 2 Years, Have You Required Help with:

Eating, Bathing, Dressing,Toileting
Transferring (walking), Continence
Myself
My Spouse
Both
Neither

Explain Required Assistance:

In the Last 5 Years Have You Been Hospitalized:

Myself
My Spouse
Both
Neither

Explain Hospitalization:

In The Past 5 Years Have You or Your Spouse:

Been admitted to a Nursing Home
Received Home Care
Received Rehabilitation
Myself
My Spouse
Both
Neither

Explain care received:

List medications you are currently taking:

List medications your spouse is currently taking:

Do you currently own a Long Term Care Program?:

Myself
My Spouse
Both
Neither

Benefit period Desired:

2 years
3 years
4 years
5 years
7 years
10 years
Lifetime

Benefit Desired - Nursing Home Coverage:

$3000 month / $100 day
$4500 month / $150 day
$6000 month / $200 day
more coverage
less coverage

Benefit Desired - Home & Community Care:

$3000 month
$4500 month
$6000 month
more coverage
less coverage

Inflation Protection/Cost Of Living Adjustment:

GPO - Guaranteed Purchase Option
3 % or 5 % simple inflation protection
3% compound inflation protection
5% compound inflation protection
No inflation protection

How long can you afford to pay for long term care:

Approximate cost for care in Colorado
$60,000-80,000 / 1 year of care
$120,000-160,000 / 2 years of care
$180,000-240,000 / 3 years of care
$250,000 +............

Comments or Questions:

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