Long Term Care Insurance

Friday, September 03, 2010

Please fill out the form below to receive your
free, no obligation quote for long term care insurance.

First off, who are you requesting this quote for?
Now, we'll need some brief information about the person(s) to be protected. Insuree:
First Name
Last Name
Date Of Birth
Health
Tobacco	(use within last year...)
Insuree Spouse: (optional)
Spouse First Name
Spouse Last Name
Spouse Date Of Birth
Spouse Health
Tobacco	(use within last year...)
Contact Information:
Street
City
State
Zip
E-mail
Fax	( ) -
Daytime Phone	( ) -
Evening Phone	( ) -
The best time to contact
Approx. Household Income

Remember, the Long Term Care Insurance Professional will be able to make contact only if you provide accurate contact information. Contact is most often made by E-mail, postal mail, fax and telephone as appropriate to best meet your needs. The object is to serve you naturally, easily and effortlessly in your quest, not pester you. It's just this simple.
Questions
1) How often do you check your e-mail?
2) Would you be willing to receive all Long Term Care Insurance information and quotes through e-mail and over the phone, or would you prefer to have an in-person consultation with the Long Term Care Insurance Professional?
3) Health history can dramatically affect Long Term Care Insurance premium cost. Would you be willing to answer several, brief health questions, so your Long Term Care Insurance Professional can help you uncover the best value? Yes No

4) Is there any reason you would NOT choose to own Long Term Care Insurance protection within the next 90 days? Yes No
If yes, what would this reason be?
5) If you currently own a Long Term Care Insurance policy, would you like a competitive comparison? Yes No
6) Please list the names of your current carrier or any companies for which you have received quotes (This info will help the Professional meet your needs more quickly and saves you both from unnecessary questions.)
7) What is your main reason for seeking coverage?
8) If there is a different reason, please share this now:
Additional Comments:
To save you time, please acknowledge the following simple facts and submit your information only if you agree with the statements below.


	YES, I WANT to make a personal connection with the Long Term Care Insurance Professional in my State, and I provided correct and accurate contact information.
	I REALIZE that the Long Term Care Insurance is not for persons with Parkinson's, Alzheimer's, memory loss, multiple sclerosis, wheel chairs, walkers, oxygen usage, on disability, needing assistance with activities of daily living or persons who have already been declined twice for Long Term Care insurance or have been told be their doctor that they need Long Term Care. (Please do not enter your info if you, or the person you are researching for, experiences any of the above health/mental conditions.)