Shane Insurance Agency Inc.

Individual Long Term Care Insurance Quote Request

No one of us wants to think about the reduction of our assets through the high costs of nursing homes and personal care, but the fact is many, if not most of us will require long term care as we age. And that care can cost $30,000 to $50,000 per year. Long Term Care insurance, sometimes called nursing home insurance, can protect against the increasingly high costs of long term care.

Contact Information
Name :
Address :
City :	State : Zip :
Phone :	Work :
	Home :
	Fax :
Email :
Personal Information
Gender :	Male Female
Date of Birth :	/ /
Height :
Weight :
Marital Status :
Spouse Information
Gender :	Male Female
Date of Birth :	/ /
Height :
Weight :
Health Information
Please indicate your tobacco use :
Please describe your health problems : (leave it blank, if not applicable)
Please list any medications you are taking : (leave it blank, if not applicable)
Describe your family's history of cancer and/or heart disease :(leave it blank, if not applicable)
Do you use :		Cane Walker Wheel Chair
Insurance Coverage
What deductible (waiting) period would you prefer?
For what period of time will you need benefits :
Do you want an inflationary rider?		Yes No	If Yes : Simple Compound