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Long-term care insurance The Lipham Group

Free Long-term Care Insurance Quote and Consultation

Please complete the following information if you would like to obtain a quote on Long-Term Care Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your e-mail address?
e-mail
What is your address?
Street
City
State
Zip
What is your telephone number?
Day
Evening
What is your fax number?
Fax
What is your birth date?
Birth Date
What is your gender?
Gender
 Male Female
What type of policy do you want?
How long of an elimination period do you want?
Would you want a long term care policy that would pay benefits for care that's received outside the United States? Yes No
Which of the below statements most accurately describes your thoughts on long term care insurance?
We've decided that long term care insurance is definitely right for us and we plan on purchasing a policy within 3 months or so. Right now we're looking for information to help us choose the policy that's best for us.
We're not sure if long term care insurance is right for us. To help us decide, we want to see what kind of benefits are available and at what cost.
Right now we want some information about costs and benefits so that we can better plan on when to move forward with a policy. It will probably be at least six months to a year before we plan on purchasing a policy.
Is there anything else that is very important for you to have in your long term care insurance policy?
Do you or your spouse own a business? Yes No
If so, what type of business entity is it for tax-filing purposes?
Are you married? Yes No Spouse's Birth Date?
Spouse's Name
Fill in spouse if spouse is also applying
 
Self
Spouse
Height?
Weight?
Do you smoke? Yes No Yes No
When did you last use a tobacco product?
What kind of tobacco product was it?
When was the last time you had a physical?
If it was more than a year ago, when was the last time you saw a medical doctor for any other reason?
Have you ever had any type of cancer? Yes No Yes No
If so, what kind of cancer was it?
When did you receive the final cancer treatment?
Have you ever had any type of stroke or mini-stroke? Yes No Yes No
If so, how many strokes or mini-strokes have you had, when was the last one, and are there any residual effects (e.g. impaired vision, paralysis, cognitive impairments).
 
Have you had any major injuries, falls or broken bones in the last 5 years? Yes No Yes No
If so, please provide details
Do you have any shot-term memory problems? Yes No Yes No
Do you have any other chronic illnesses? Yes No Yes No
Please give as much detail as possible.
Are you currently receiving any type of disability payments or worker's compensation payments? Yes No Yes No
If so, what is the cause of disability?
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:
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
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other: