LTC Quote Request Form

LTC Insurance Quote Request for Brokers

Click here to download Quote Request Form in Printable Format

How the Quote Process Works:

Complete this form and click the SUBMIT NOW button below.

We will automatically receive your information and begin working on your LTC quote immediately. An LTCi Advisor will contact you with a prompt and educated response!

*For an accurate proposal, complete the form in its entirety.

LONG TERM CARE INFORMATION	CLIENT INFORMATION

Desired insurance rate class	Name:
	State:
Total Long Term Care Benefit	DOB/Age:
	Sex:
Monthly Long Term Care Benefit
	PARTNER INFORMATION
Elimination Period	Name:
	DOB/Age:
Inflation Protection	Sex:


Additional Riders (select all that apply)

Shared Care
Shared Waiver
Restoration of Benefits
Survivorship
10 Yr. Payment
To Age 65 Premium
Cash Benefit
Return of Premium

Quote Specific Company & Product (select all that apply)

MedAmerica (CASH)
Prudential
Mutual of Omaha
Genworth
LTC Annuities
Critical Illness Insurance
Final Expense

Explain all medical conditions and medications for last 5 years (PRIMARY):


Explain all medical conditions and medications for last 5 years (PARTNER)

REQUIRED BROKER INFORMATION Without this information, we cannot forward the quote.
*Broker Name:

*Phone:

*Fax:

*Email:

Corporate Headquarters
15830 Venture Lane, Eden Prairie, MN 55344
Phone: 952.937.9127 Toll Free: 800.848.5080 Fax: 952.937.7605