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With the average American Baby Boomer reaching retirement, Long-Term Care insurance should be on the minds of many people today.  Long Term Care Insurance protects you, as well as your loved ones in the advent that extended care is needed during your life  Would you like a FREE no obligation Long Term Care Insurance Quote? You could save substantially for two minutes of your time

First Name


Last Name


Street Address






Zip Code


Day Phone


Evening Phone


E-mail Address


What is the best time to call:


Who is this quote for?




Birthday (mm/dd/yy)



 feet inches



Name of parent (if different)
(otherwise, leave blank)


Are you married?

Yes     No 

Do you smoke?

Yes     No 

Are you diabetic?

Yes     No 

Are you insulin-dependent?

Yes     No 

Do you use any of the following:

   wheel chair

If you use other medical
equipment, please describe
 (otherwise, leave blank)


If you've required assistance with your everyday activities in the past 2 years please explain.
(otherwise, leave blank)


In the past 5 years, have you:

   been confined to a hospital/nursing home
   had home care
   had long term care
   recieved rehabilitation

If you have any particular health problems, please describe
 (otherwise, leave blank)


Would you like an additional quote on any of the following insurance or home loan products?

  Life Insurance
  Annuities (Retirement Vehicle)
  Disability Insurance
  Health Insurance
  Group Health Insurance
  Auto Insurance
  Homeowners Insurance
  Home Loans