Skip to main content
home
get aip
about us
contact us
home
Group Long Term Care Quote
Group Long Term Care Insurance Quote
Contact Information
Group Name:
Telephone:
Group Contact:
Fax:
Group Address:
E-Mail Address:
City, State & Zip:
# of employess to be insured:
Type of Business:
How long in business:
Do you currently offer long-term care insurance to employees?
Yes
No
Want long-term care insurance coverage for:
Select One
All Employees
Management Only
Owners Only
Management + Owners Only
Give a complete description of any type of hazardous/dangerous duties performed by your employees:
Current Group LTC Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:
Premium Amt:
$
Years Insured:
Please give a brief description of your
current Group LTC plan:
Coverage Options
Type of Coverage:
New Coverage
Additional Coverage
Replacement
Waiting Period:
Please Select
0
30 Days
60 Days
90 Days
180 Days
365 Days
Daily Benefit Amount:
Please Select
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
240
250
Benefit Period:
Please Select
2 years
3 years
4 years
5 years
Lifetime
Inflation Protection:
Please Select
None
Simple
Compound
Do you want your policy to include
home-health care coverage?
Yes
No
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:
Employee #
Employee Name
Birth Date (mm/dd/yy)
Gender
Salary
Select Coverage
# 1
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 2
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 3
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 4
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 5
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 6
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 7
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 8
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 9
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
# 10
Gender
Male
Female
Coverage
Employee Only
Employee & Spouse
Employee & Children
Family
Additional Comments
Please give any additional comments or questions
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.
