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Correira Insurance Agency, Inc.
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 LTC Quote 
Form: ltc Quote
Long Term Care Insurance Quote




Contact Information
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
Deliver quote via
E-Mail Fax Regular Mail Telephone
No coverage of any kind is bound or implied by submitting information via this online form
We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

By completing this form, you are acknowledging your understanding of and agreement with these terms

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