california retirement insurance quote: Free long Term Insurance quote California, ca

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Long Term Care Insurance Quote

Contact Information

1	*First Name:
2	*Last Name:
3	*Daytime Telephone:
4	Fax:
5	*Email:
6	*Address:
7	*City:
8	*State:
9	*Zip:

About You

10	Date of Birth:
11	Gender:	Male Female
12	Height:
13	Weight:
14	Are You Married?	Yes No Spouse Birthdate

Please Complete for Self/Spouse

		Self	Spouse
15	Do you smoke?	Yes No	Yes No
16	Are you diabetic?	Yes No	Yes No
17	Are you insulin dependent?	Yes No	Yes No
18	Do you use a cane?	Yes No	Yes No
19	Do you use a walker?	Yes No	Yes No
20	Do you use a wheel chair?	Yes No	Yes No
21	Do you use any other equipment?	Yes No	Yes No
22	If you have required assistance with everyday activities in the past 2 years, please explain:
In the past 5 years have you:		Self	Spouse
23	Been confined to a hospital?	Yes No	Yes No
24	Been in nursing home?	Yes No	Yes No
25	Had home care?	Yes No	Yes No
26	Had long-term care?	Yes No	Yes No
27	Received rehabilitation?	Yes No	Yes No
28	Please describe your particular health problems:
29	Prescribed medications:
30	Do you currently own a long-term care policy?	Yes No	Yes No

Long Term Care Selections

31	Benefit period desired:	(Average stay in a nursing facility is about 3 years)
32	Daily Benefit - nursing home coverage:
33	Daily benefit - home & community care:
34	How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?	(Average cost per month is $5,000 which could be more depending on area of country)
35	Inflation protection/cost-of living adjustment:	(Most needed for younger applicants)

Comments or Questions

36
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This preliminary quote is for the insurance coverage you selected and based on the information you entered. A quote is not an offer for insurance nor an insurance contract. Rates quoted reflect the rates in effect as of the date of this quote and are subject to revision. To obtain coverage, you must have an application submitted by a Farmers® agent. Farmers® reserves the right to accept, reject, or modify this quote after review of the application and other underwriting information. All applications are subject to underwriting approval.

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