Premier Services - The Insurance Experts

Long Term Care Application Form
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

Name:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Sex:

Date of Birth (MM/DD/YY):

Are you a:

Are you married?

Are you on any medication? If so, please list details:

Describe any health problems:

Daily benefit to be paid - please choose between $50 and $200:

Pick a benefit period:

Elimination period:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What was the price quoted?

Please describe the plan in detail (co-insurance, type of plan, deductible, maximum benefit, etc.):

How did you hear about us?

Additional Comments: