Long-Term-Care Insurance QuoteAssociate.com will take your information and match your policy needs with one reputable insurance agency in your community. Please fill out the application below completely and an insurance agent will contact you within 24 business hours with a fast free and accurate insurance quote. QuoteAssociate.com is not an insurance agency, broker, wholesaler, or underwriter nor do we sell your personal information to any third party.

° Contact Info
First Name:
Last Name:
DOB:
E-Mail:
° Address Info
Street Address:
City:
State:	-- Choose State -- 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 NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code:
Home Phone Nbr:
Work Phone Nbr:
When is the best time to reach you?:	-- Choose One -- Anytime Morning at Home Afternoon at Home Night at Home Morning at Work Afternoon at Work Night at Work Weekends
Gender:	MaleFemale
Company/Employer:
Marital Status:	MarriedSingleDivorced
What is your credit like?:	PoorFairGoodExcellent
Social Security Number (Optional)**:
Can one local insurance agent run your credit?:	YesNo
° Long-Term-Care Insurance Info
1. How would you classify your health?:	-- Choose One -- Excellent Good Fair Poor
2. Do you have any serious health problems?:	YesNo
If so, please give explaination?:
3. Have you used tobacco in the last 3 years?:	YesNo
4. Benefit period desired?:	-- 3 Years 5 Years 10 Years 20 Years
5. Daily Nursing Home Coverage?:	-- 110 130 140 150 200
6. Do you want coverage for Home Care?:	YesNo
If yes, Choose Daily Benefit	-- 110 130 140 150 200
7. How many days after care is needed would you like the benefits to begin? :	-- 0 Days 2 Days 3 Days 4 Days 5 Days 10 Days 15 Days 20 Days
8. Would you like Inflation Guard Benefits? :	YesNo
9. Spouse's Name:
Spouse's DOB:
11. How would you classify your Spouse's health?:	-- Choose One -- Excellent Good Fair Poor
12. Does your spouse have any serious health problems?:	YesNo
If so, please give explaination?:
13. Has your spouse used tobacco within the last 3 years?:	YesNo
Do you currently own a long-term care policy? :	YesNo
Add any comments including any health concerns you may have:

What is Long Term Care Insurance?

Long-term care insurance, an insurance product sold in the United States, helps provide for the cost of long-term care beyond a predetermined period. Long-term care insurance covers care generally not covered by health insurance, Medicare, or Medicaid.

Individuals who require long-term care are generally not sick in the traditional sense, but instead, are unable to perform the basic activities of daily living such as dressing, bathing, eating, toileting, getting in and out of a bed or chair, and walking.

Long-term care isn't necessarily long term. A person may need care for only a few months to recover from surgery or illness.

As an individual ages, there is an increased risk of needing long-term care. In the United States, Medicare will not cover the expenses of long-term care, but Medicaid will for those who can not afford to pay.