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Online Insurance Quotes: Online Insurance Quotes: What would happen to your family if you were to need nursing home care?  With Long Term Care insurance you (or your parents) won't have to worry about paying for extended care. Get a FREE no obligation Long Term Care Insurance Quote!  You could save substantially for two minutes of your time

The short form below should be filled out as completely as possible in order to receive an accurate quote.

First Name

Last Name

 

Street Address

City

 

State

Zip Code

Day Phone

 

Evening Phone

 

E-mail Address

Best time to call:

Who is this quote for?

Gender

Birthday (mm/dd/yy)

  19

Height

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Weight

lbs.

Name of parent (if different)
(otherwise, leave blank)

Are you married?

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Do you smoke?

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Are you diabetic?

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Are you insulin-dependent?

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Do you use:

  cane
  walker
  wheel chair

If you use other medical
equipment, please describe
(otherwise, leave blank)

 

If you've required assistance with your everyday activities in the past 2 years please explain.
(otherwise, leave blank)

 

In the past 5 years, have you:

  been confined to a hospital/nursing home
  had home care
  had long term care
  recieved rehabilitation

If you have any particular health problems, please describe
(otherwise, leave blank)

 

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