Long-Term Care Insurance Application


States require paper applications to be filled out and submitted, online applications are not yet available for long term care insurance.

After you fill out the form below we will email or mail your application (your choice) with instructions, and we have phone support if you need assistance with the forms. The application sent will be based on the company with the lowest premium for your age and state.

At this stage you are only applying for approval and are not committed to the insurance or to the benefits of the plan. Approval takes 3-6 weeks. Once approved you will be sent a policy proposal and have by state law 30 days to keep it, change it, or cancel it.

We represent all the major long term care insurance carriers and do not have a preference. We will provide you with the lowest premiums for the benefits you select. The premiums are the same if you buy your insurance through us, another agent or agency, or directly from the company.

Please fill out the entire form. We do not sell or share your information.

If you are uninsurable you have other options, contact us for more information

Full Name :

Age
Second Applicant:

Age

Status
Single Married Partner/Sibling

How much daily benefit do you want?

How long do you want benefits for?

I want the application sent by:
Email Postal Mail
I want to meet with an agent: Yes No

Street Address, City, State, Zip
(required to send application)

E-mail:
(required to email application)

I would like phone assistance with the application. Yes No

Phone: (entry required)
*home, work, cell or repeat email
Best days to contact you:
M-F Sat Sun
Best times to contact you: AM — PM



Call toll free 1-888-582-2464
or Email us if you have any questions.