Long-term Care Quote Request - THE BROKERAGE RESOURCE

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About & Contact

LONG-TERM CARE QUOTE REQUEST

Client Information

* Indicates required field

Name of Insured *

First

Last

Name of Co-Insured *

First

Last

[object Object]

Date of Birth *

Date of Birth *

Gender *

Gender *

Married *

Yes No

Height *

Enter as 5'7" format.

Weight *

Net Worth *

State *

U.S. Resident? *

Yes No

U.S. Citizen? *

Yes No

Resident Country (if not U.S.) *

Tobacco Use *

Yes No

If yes, date last used. *

Type of Tobacco Used *

Coverage Details

Daily or Monthly Benefit $ *

Payment Options *

Limited Pay Annual Pay

Inflation Option *

Premium Goal $ *

Benefit Period (Years) *

Elimination Period (Days) *

Has client ever been declined or rated for insurance? *

Yes No

If declined or rated, please provide details and company. *

Medical Provider

Date Last Consulted *

Reason for Visit *

Current Medications *

Diagnosis *

Health Questions

Cancer *

Yes No

Diabetes *

Type 1 Type 2

Cardiovascular *

Heart Stroke High Blood Pressure

Age at Diagnosis *

Age at Diagnosis *

Other Conditions *

Mental/Nervous Respiratory Kidney Gastrointestinal

Cancer Type/Location *

A1C *

Substance Abuse *

Drugs Alcohol

Select if applicable. *

Quad Cane Wheel Chair Walker Scooter Oxygen

Select if applicable. *

Alzheimer's Dementia Parkinson's Multiple Sclerosis Lupus COPD

Confined to a facility or received therapy in last six months? *

Yes No

Receiving disability benefits or eligible for Medicaid? *

Yes No

Other Details & Concerns *

Agent Information

Agent *

Phone *

Email *

Agency *

City *

State *

Submit

Connect

800.928.4998
919.489.3600
919.419.0401 (fax)
info@tbrins.com

1480 Chapel Ridge Road
Suite 200
Apex, NC 27502

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