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Request a Quote -- Long Term
Care Insurance
We make every
effort to answer all inquiries within 24 hours or less.
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*Required Fields
Yes, I would
like to get a quote for Long Term Care Insurance.
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I would prefer a reply
by: |
Email |
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Telephone |
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I would like the
insurance to cover: |
Myself
Only |
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Myself
& Spouse |
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Does any one use tobacco products? If
yes, who? If no, leave blank. |
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Does any one participate in hazardous
sports or activities such as racing, rock climbing, etc.? If
yes, who & what? If no, leave blank. |
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Does any one have any major health
that would affect your ability to live unassisted? If yes, who &
what? If no, leave blank. |
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Does any one take any medications? If
yes, who & what? If no, leave blank. |
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Does any one use a cane, walker or
wheel chair? If yes, who & what? If no, leave blank. |
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In the past 5 years, has any one been
confined to home, needed home care or previously been in an
assisted living facility or nursing facility If yes, who &
for how long under care? If no, leave blank. |
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Comments, Questions or Special needs: |
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We
attempt to answer all inquiries within 2 working days, but usually within
24 hours. |
Thank you for your inquiry! |
© 2001-2006 Health Insurance
of Washington. All Rights Reserved.
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