Ken Leshaw Agency

Long Term Care Insurance Quote Form

Contact Information
Name:
Address:
City:	State: Zip:
Phone:	Work:
	Home:
	Fax:
Email:
Personal Information
Gender:	Male Female
Date of Birth:	/ /
Height:
Weight:
Marital Status:
Spouse Information
Gender:	Male Female
Date of Birth:	/ /
Height:
Weight:
Health Information
Please indicate your tobacco use:
Please describe your health problems : (leave it blank, if not applicable)
Please list any medications you are taking: (leave it blank, if not applicable)
Describe your family's history of cancer and/or heart disease: (leave it blank, if not applicable)
Do you use:		Cane Walker Wheel Chair
Insurance Coverage
How much amount you want for a daily benefit?			$
What deductible (waiting) period would you prefer?
For what period of time will you need benefits:
Do you want an inflationary rider?		Yes No	If Yes: Simple Compound