1.  Contact Information:  To what address do you want the quotes mailed and/or e-mailed:

First Name:
Last Name:

Preferred e-mail address: 

Mailing Address:
City:
State:
Zip:

Preferred Phone:
 

2.  Do you currently own a long term care policy? 
If you already own a long term care insurance policy, and want to compare your current coverage, check this box:     How long have you owned your current policy:  --None--Less than six months 6 to 12 months 12 to 24 months about 2 to 3 years about 4 years over 5 years

 

3.  Potential Tax Savings:  In order to make you aware of the available tax deductions, tax credits, and tax-favored methods for paying for long term care insurance, please check all the boxes that apply to yourself or to your spouse/partner:

Do you have any type of self-employment income
(either part-time or full-time):

Do you own a Health Savings Account (H.S.A.):

Do you usually itemize your federal tax return:

Do you own your own business?:

Are you (or your spouse/partner) an actively employed (or a retired)
public safety worker (i.e. police officer, firefighter, paramedic):
 

4.  Home Healthcare Benefits:  Nearly every long term care insurance policy that can be purchased today will pay benefits for qualified care that you receive in any of the four, main "Care Settings":  nursing homes, assisted living facilities, adult day care, as well as in-home care.  However, some policies pay only 50% to 75% of the benefits when care is received at home. We can design a policy that allows for 100% of the benefits to be used for in-home care. 
Check this box if it is important for you to be able to receive as much care at home
for as long as possible?:
 

5.  Cost-Sharing:  Check the box at the end of the statement which best describes you:

a)  If I (or my spouse/partner) were to need care sometime in the future and the care cost $100,000 each year, I would be comfortable owning a long term care insurance policy that would pay $85,000 towards the cost of care each year; and I would be able to make up the difference in the cost by using some of my own income and/or some of my own savings.

b)  If I (or my spouse/partner) were to need care sometime in the future and the care cost $100,000 per year, I would prefer to have a long term care insurance policy that covered nearly every penny of the long term care expenses. I would not want to use my own income and/or savings to help pay for the costs of the care. I would be willing to pay a higher premium for a policy like this that more fully covered the costs of care.
 

6.  Current and Future State(s) of Residence:  To make sure we more thoroughly research the various policies available for  you, please answer the following questions regarding your state(s) of residence:

What is your primary state of residence: --None--ALABAMA AL ALASKA AK ARIZONA AZ ARKANSAS AR CALIFORNIA CA COLORADO CO CONNECTICUT CT DELAWARE DE DISTRICT OF COLUMBIA DC FLORIDA FL GEORGIA GA HAWAII HI IDAHO ID ILLINOIS IL INDIANA IN IOWA IA KANSAS KS KENTUCKY KY LOUISIANA LA MAINE ME MARYLAND MD MASSACHUSETTS MA MICHIGAN MI MINNESOTA MN MISSISSIPPI MS MISSOURI MO MONTANA MT NEBRASKA NE NEVADA NV NEW HAMPSHIRE NH NEW JERSEY NJ NEW MEXICO NM NEW YORK NY NORTH CAROLINA NC NORTH DAKOTA ND OHIO OH OKLAHOMA OK OREGON OR PENNSYLVANIA PA RHODE ISLAND RI SOUTH CAROLINA SC SOUTH DAKOTA SD TENNESSEE TN TEXAS TX UTAH UT VERMONT VT VIRGINIA VA WASHINGTON WA WEST VIRGINIA WV WISCONSIN WI WYOMING WY
Is there a second state in which you regularly reside?: --None--ALABAMA AL ALASKA AK ARIZONA AZ ARKANSAS AR CALIFORNIA CA COLORADO CO CONNECTICUT CT DELAWARE DE DISTRICT OF COLUMBIA DC FLORIDA FL GEORGIA GA HAWAII HI IDAHO ID ILLINOIS IL INDIANA IN IOWA IA KANSAS KS KENTUCKY KY LOUISIANA LA MAINE ME MARYLAND MD MASSACHUSETTS MA MICHIGAN MI MINNESOTA MN MISSISSIPPI MS MISSOURI MO MONTANA MT NEBRASKA NE NEVADA NV NEW HAMPSHIRE NH NEW JERSEY NJ NEW MEXICO NM NEW YORK NY NORTH CAROLINA NC NORTH DAKOTA ND OHIO OH OKLAHOMA OK OREGON OR PENNSYLVANIA PA RHODE ISLAND RI SOUTH CAROLINA SC SOUTH DAKOTA SD TENNESSEE TN TEXAS TX UTAH UT VERMONT VT VIRGINIA VA WASHINGTON WA WEST VIRGINIA WV WISCONSIN WI WYOMING WY
 

7.  Future Costs of Care:  As the demand for care has increased, long term care expenses have risen significantly. Care that currently costs $80,000 per year, is projected to cost almost $200,000 per year 20 years from now.

Is it important for you to have a long term care policy that will grow each year to try to keep pace with the increasing costs of care?  If so, check this box here:
 

 

8.  Inflation Increases:  Nearly every  long term care policy has some type of feature to help protect you against the increasing cost of care.  There are 2 main types:

Type 1:  Some policies are designed in such a way that the premium starts off lower and then the premium goes up 5% or more each year as the benefits increase each year.  The benefits in these policies double about every 15 years.  This type of policy can double in cost about every every 12 to 15 years.

Type 2:  Other policies start off with higher premiums now, but the benefit increases are automatically built into the premium. With this type of policy, the increases in the benefits each year do not make the premium go up each year.


Check the statement which best describes you:

(Type 1)  I would prefer a policy that starts off with a lower premium now and have the premium increase each year by 5% or more, as the benefits increase each year:

-OR-

(Type 2)  Even though it starts off with a higher premium now, I would prefer a policy that has the inflation benefits built into the policy from the beginning. This way I will have a more stable and a more predictable premium over a longer period of time:
 

 

9.  Protection of Your Assets or Income:  Please check all that apply. 

Is it important for you to protect your assets or your income for:

A disabled child or relative:
Charitable organizations:
Your own financial independence:
The financial independence of your spouse or partner:
Your heirs

If it's not important  for you to protect your assets or income, check this box::
 

 

10.  Lifetime Maximum Benefit (Policy Limit):  Nearly every type of insurance policy has some kind of "Policy Limit". Your homeowner's insurance, your auto insurance, and even your medical insurance, has some kind of "Policy Limit". 

With long term care insurance, you can choose to have a policy with a "limit" or you can choose a policy that has "no limit". Of course, a policy with "no limit" is more expensive than the same policy with a limit.

What's unique about long term care insurance is that your policy limit grows each year according to the Inflation Benefit that you choose for your policy. For example, you might choose a policy with a starting limit of $250,000 and a 5% Compounded Automatic Inflation Benefit. The policy would start off with a $250,000 Lifetime Maximum Benefit, but it would grow to over $500,000 within 15 years and continue to grow to over $1,000,000 worth of benefit within 30 years.

About how much do you think you'd want your starting policy limit to be?: --None--Not Sure $200,000 $250,000 $300,000 $400,000 $500,000 $750,000 $1,000,000 Unlimited (no limit)
 

 

11.  Your Thoughts about Long Term Care Insurance:  Which of these statements most accurately describes your thoughts on long term care insurance?

a)  I've decided that long term care insurance is definitely right for me and I plan on purchasing a policy within 3 months or so. Right now I'm looking for information to help me choose the policy that's best for me:

b)  I'm not sure if long term care insurance is right for me. To help me decide, I want to see what kind of benefits are available and at what cost.:

c)  Right now I want some information about costs and benefits so that I can better plan on when to move forward with a policy. It will probably be at least six months to a year before I plan on purchasing the policy.:
 

12.  If there are any other matters which are important to you in designing and choosing your long term care policy, please share that information in the box below.  Enter any additional details about what benefits you want included in your long term care insurance policy, including any features or benefits that you consider important.  Also feel free to enter your thoughts regarding: daily benefit, inflation benefit, benefit period, elimination period, care settings, financial ratings, premium rate stability, etc...: