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About You * First Name * Last Name * Email * Email (retype) * Street Address * City Select State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming * * Zip Ext. * Phone (Day) * Phone (Evening) Fax Your Long Term Care Insurance Information Do you currently have Long Term Care insurance? Yes No If you answered 'yes' to having health insurance: When does your current policy expire? (mmddyyyy) Who are you currently insured with? Are you a Male Female * Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 * What is your birthdate? Feet 1 2 3 4 5 6 7 8 Inches 0 1 2 3 4 5 6 7 8 9 10 11 Your height lbs. Your weight What deductible (waiting) period would you prefer? 0 days 30 days 60 days 90 days 180 days 365 days Benefit Period? 2 years 3 years unlimited Maximum Daily Benefit? $100 a day $120 a day $250 a day When did you last use any tobacco products? Never Currently 1 year ago 2 - 4 years ago 5 or more years ago Do you want an inflationary rider? With 5% Without To your knowledge, is there any family history (grandparents, parents, or siblings) of cardiovascular disease before the age of 60? Yes No Optional Coverage Include Spouse in quote? Yes No Spouse is a Male Female What is your spouse's birthdate? Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Feet 1 2 3 4 5 6 7 8 Inches 0 1 2 3 4 5 6 7 8 9 10 11 Spouse's Height lbs. Spouse's Weight When did your spouse last use tobacco products? Select One Never Currently 1 year ago 2 - 4 years ago 5 or more years ago Additional Coverage? (check the ones you may want) Health Insurance Long Term Care Prescription Card Senior Care Supplemental Accident Disability Insurance Maternity Life Insurance Details Any Comments / Questions? Want to receive relevant information from InsuranceFinder? Yes No **For the courtesy of our insurance partners, please only submit this inquiry if you are truly interested.		Your site is the the most helpful and insightful insurance site I have visited! And its FREE!!! Anything free is for ME!!! Thanks a lot and I appreciate your tips! I will let you know the outcome! Great site!!! Great information. Very informative. I just want to say "Thank you". The services you have provided are awesome. Keep up this great service. So far I have found that you have done exactly what you say. And that is the best thing! Thank you. Great information. Thanks for providing! Thank you very much for your help!! You made it so easy to find exactly what I needed. I will be telling my friends and family about your website. Again, thanks a lot!!

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