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 Group Long Term Care Quote 
Group Long Term Care Insurance Quote

Contact Information
Group Name:
Telephone:
Group Contact:
Fax:
Group Address:
E-Mail Address:
City, State & Zip:
# of employess to be insured:
Type of Business:
How long in business:
Do you currently offer long-term care insurance to employees?
Yes   No
Want long-term care insurance coverage for:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:
Current Group LTC Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:
Premium Amt:
$
Years Insured:
Please give a brief description of your
current Group LTC plan:
Coverage Options
Type of Coverage:
New Coverage
Additional Coverage
Replacement
Waiting Period:
Daily Benefit Amount:
Benefit Period:
Inflation Protection:
Do you want your policy to include
home-health care coverage?
Yes   No
Employee Information
(If More Than 10 Employees, place call us to receive a large group census form or use the additional comments box below to add remaining employees.)
Please list all employees you wish to cover:
Employee #
Employee Name
Birth Date (mm/dd/yy)
Gender
Salary
Select Coverage
# 1
# 2
# 3
# 4
# 5
# 6
# 7
# 8
# 9
# 10
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.


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