Group Long Term Care Insurance Quote
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Group Name: |
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Telephone: |
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Group Contact: |
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Fax: |
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Group Address: |
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City, State & Zip: |
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E-Mail Address: |
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# of employess to be insured: |
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Type of Business: |
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How long in business: |
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Do you currently offer long-term care
insurance to employees? |
Yes
No |
Want long-term care insurance coverage
for: |
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Give a complete description of any type
of hazardous/dangerous duties performed by your employees: |
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Current Group LTC Insurance Information
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Carrier (Company) Name (not agency): |
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Policy Expiration Date: |
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Premium Amt: |
$
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Years Insured: |
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Please give a brief description of your
current Group LTC plan: |
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Coverage Options |
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Type of Coverage: |
New Coverage
Additional Coverage
Replacement |
Waiting Period: |
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Daily Benefit Amount: |
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Benefit Period: |
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Inflation Protection: |
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Do you want your policy to include home-health
care coverage? |
Yes
No |
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Employee Information
(If More Than 10 Employees, place call us to receive
a large group census form or use the additional comments box below
to add remaining employees.)
Please list all employees you wish to cover:
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Additional Comments
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Please give any additional comments or
questions |
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| No coverage of any kind
is bound or implied by submitting information via this online form
- We will only use information provided to assist in obtaining appropriate
insurance quotes and coverage.
- We will not distribute information to other parties other than for
insurance underwriting purposes.
- By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
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