Long Term Care LONG TERM CARE - INFORMATION AND QUOTE REQUEST
For Residents of Illinois Only

Easy To Use Quote Request Form  

Your name
Address
City & State
Zip Code
E-mail Address
AM PH# (Inc. Area Code)
PM PH# (Inc. Area Code)
Your date of birth
Your Gender Male Female
Do you want to cover your spouse also? Yes No
If 'Yes," what is your spouse's date of birth:  

In the past 6 mths, have you/your spouse been hospitalized or been confined to a nursing home? Yes No
Are you (or your spouse) currently bedridden? Yes No
Within the past two years, have you (and/or your spouse) had chronic obstructive pulmonary disease, rheumatoid arthritis, internal cancer, Hodgkin's disease, melanoma, Alzheimer's disease, Parkinson's disease, MS, MD, Lou Gehrig's disease or osteoporosis? Yes No

Comments or special requirements should be noted here?

I understand that this service merely provides a proposal request and is not a Policy of Insurance, Application or Offer to Insure on behalf of any Insurance Company, Agency or Agent. Individual companies reserve the right to accept, reject or modify a proposal after investigation and review.