Agent/Professional
LTC Insurance Quote Request

Agent/Professional Request For Quote

This form is for Insurance Agents and Other Professionals who are seeking a QUOTE on Long Term Care Insurance for THEMSELVES or SOMEONE OTHER THAN THEMSELVES.

We will need some additional information to provide the quote. After we receive your request we may contact you by phone to answer a few "health related" questions. We will not be able to provide the quote without all of the following information.
(all fields are required)

*What is your Email Address:
This is important - we need this in case we have a question
& are unable to process your request.
We *NEVER* sell or share email addresses with anyone.
(AOL Members: Please enter your WHOLE email address
Simply, add "@aol.com" to your screenname
Example: chuck2341 = chuck2341@aol.com)
If you don't have an EMAIL ADDRESS, please Click Here

*What is your DAY Phone Number:
(Please include your AREA CODE, failure to provide a valid phone number
or entering bogus data will cause your request to be deleted)

*What is your EVENING Phone Number:
(Please include your AREA CODE, failure to provide a valid phone number
or entering bogus data will cause your request to be deleted)

At least once a day, we send an email message that BOUNCES (cannot be delivered) because of an mis-typed/incorrect email address. PLEASE double check your email address and phone number now and type YES once you've confirmed that they are entered correctly.

Have you entered your email address and phone numbers correctly?

*Do You Currently Sell Insurance?:
[Yes ] [No ]

*If You Are Selling Insurance, Are You Selling LTC Insurance?:
[Yes ] [No ]

*What is YOUR Primary Profession:
PLEASE Select From List Below Insurance Agent Attorney Financial Planner Investment Professional (Stockbroker, etc) Social/Case Worker Other (please explain below)

Other Profession (from previous question):
(you may also use this field for a brief comment if you wish)

**THIS IS A VERY IMPORTANT QUESTION**

*Who are you looking into this for:
(Who is this QUOTE for?)
PLEASE Select From List Below Myself/Ourselves Family Client(s) Friend(s) Neighbor(s) Other (please explain below)

Other (from previous question):
(you may also use this field for a brief comment if you wish)

*How did you hear about this LTC Insurance Info Page?:
(please be specific, it helps us to know this information)

PLEASE Select From List Below -------------------- Search Engines -------------------- Yahoo! Goto Search Engine AltaVista Search Engine Excite Search Engine HotBot Search Engine LinkStar Search Engine WebCrawler Search Engine InfoSeek Search Engine Lycos Search Engine Magellan Search Engine PlanetSearch Search Engine What-U-Seek Search Engine AskJeeves Search Engine DogPile Search Engine AOL.COM/Netfind Search Engine Unknown Search Engine -------------------- Other Sources -------------------- Recommendation/Link on another site It was mentioned in a newspaper/magazine article From a Friend/Co-Worker/Family/Someone Else Read about it on a NEWSGROUP I don't remember... -------------------- Thanks for providing this info! --------------------

**IMPORTANT**

Now we need some information about the person(s)
for whom you are requesting this QUOTE.

If you are requesting it for YOURSELF,
just answer the questions with YOUR OWN information...

If you are requesting this information for SOMEONE ELSE,
then answer these questions with THEIR information!

Please note: rates vary by state, so it is important that we know the address of the person for whom the quote is needed.

*What is YOUR/THEIR Salutation:
[Mr. ] [Mrs. ] [Ms. ] [Miss. ]

If you are requesting this information for YOURSELF, then please RE-TYPE your name as you typed it above...

*What is YOUR/THEIR First & Last Name:

*What is YOUR/THEIR Spouse's Name:
(enter "n/a" or "not applicable" if no spouse exists)

Once again, if you are requesting this information for YOURSELF
then provide YOUR information...

but if you are requesting this information for SOMEONE ELSE,
then answer these questions with THEIR information!

*What is YOUR/THEIR Street Address:
(line 1)

What is YOUR/THEIR Street Address:
(line 2)

*What is YOUR/THEIR City:

*What is YOUR/THEIR State:
(Please select the 2-letter abbrev. for your state)

PLEASE Select From List Below AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

*What is YOUR/THEIR Zipcode:
(Please supply the nine-digit zip if you know it)

Now we need some birthdates...

What is YOUR/THEIR Birthday
(NOTE: You can select "00" for DAY if you don't want to disclose actual birthdate):
MONTH:
SELECT MONTH 01 02 03 04 05 06 07 08 09 10 11 12 DAY:
SELECT 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 00 YEAR:
SELECT 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 or later

What is YOUR/THEIR Spouse's Birthday
(NOTE: If there is no spouse, just select the "00" option for MONTH, DAY and YEAR):
MONTH:
SELECT MONTH 00 01 02 03 04 05 06 07 08 09 10 11 12 DAY:
SELECT DAY 00 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:
SELECT YEAR 0000 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 or later

Two more questions and we are done!

*Have YOU/THEY already APPLIED for a LTC Insurance Plan
(or do they already have a policy)?:
[Yes ] [No ]

*Do YOU/THEY plan to PURCHASE LTC Insurance in the next 30-90 days?:
[Yes ] [No ]

OK, now the last step...
Go back over your answers
When you are done just press SUBMIT!