Long Term Care Proposal

Your Name
Email Address
Mailing Address
City
State
Zip Code
Type of Proposal
Your Date of Birth
Spouse's Date of Birth (if applying also)
List any health problems and any prescription medication you (and spouse if applicable) are currently taking. If none, please state so.
Do You Smoke?
Spouse Smoke? (if applying also)
Benefit Period Desired (Average stay in a nursing facility is about 3 years)
Daily Benefit-Nursing Home Coverage
Daily Benefit-Home & Community Care (Choose this by itself if desired. Policies including BOTH facility & home care cost more)

How long can you afford to pay for a stay in a Nursing Home ($3,000 to $6,000 per month; depending on area of country) out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc.?

Inflation Protection/Cost-of-living Adjustment (most needed for younger applicants)
Do you currently own a Long Term Care Policy?
Phone Number (Serious Inquiries Only Please)
Initial Method of Proposal	Email First PleaseTelephone