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Disability Income Insurance

Long Term Care Insurance

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    Financial devastation caused by prolonged physical or mental illness can be tremendous. The national average cost of nursing home care is about $160 per day or $58,000 per year. Home care cost is also increasing dramatically.
    We represent our clients in the Long Term Care insurance marketplace. Our goal is to help you find the policy that protects the assets you were able to accumulate during your life, so you can leave a legacy for future generations.
    Please contact us and we will show you a comparison of several policies and will help you understand the difference between plans.
Information Request for Long Term Care Insurance


First Name: 

Last Name: 

M.I.: 

Address: 

City:     State:    Zip Code: 

Email Address: 

Daytime Phone Number: 

Evening Phone Number: 

Best Time to Reach You:  Morning  Afternoon  Evening

Birthdate:       Sex:  Male  Female

Height:   feet   inches     Weight:   lbs.

Requested daily benefit:

If Other, please specify amount in $: 

Health: 

List of Medications, if any:


Do you smoke cigarettes?
Yes  No

List of Medications, if any:


Hospitalized in the past five years?:  Yes  No

Requesting information for your spouse? (You can get a significant spousal discount):  Yes  No

Spouse's Date of Birth: 

Spouse's Height:   feet   inches     Spouse's Weight:   lbs.

Spouse Hospitalized in the past five years?:  Yes  No

Health: 

List of Medications, if any:


Comments or Questions:


  I understand that my private information will be strictly confidential and will not be released to any third party.

  I understand that one of the experienced insurance professionals will contact me over the phone.



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