Request A Long Term Care Quote

Complete the following information in you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information:

Last Name:
First Name:
Email Address:
Street Address:
City:
State:
Zip Code:
Phone Number:
Alternate Phone:
Fax:
Birth Date:
Gender
Female
Height (example: 5'8"):
Weight (lbs.):
Are you married?
No
If yes, Spouse's Birth Date:
Do you smoke?
No
Spouse smoke?
No
Are you Diabetic?
No
Spouse Diabetic?
No
Are you insulin dependent?
No
Spouse insulin dependent?
No
Do you use a cane?
No
Spouse use a cane?
No
Do you use a walker?
No
Spouse use a walker?
No
Do you use a wheelchair?
No
Spouse use a wheelchair?
No
Do you use any other equipment?
No
Spouse use any other equipment?
No
Please explain if you have required assistance with everyday activities in the past 2 years:
Please explain if your spouse has required assistance with everyday activities in the past 2 years:
In the past 5 years, have you: (check all that apply)
Please describe your particular health problems:
In the past 5 years, has your spouse: (check all that apply)
Please describe your spouse's particular health problems:
Prescribed Medications:
Spouse's Prescribed Medications:
Do you currently own a long-term care policy?
No
Does your spouse currently own a long-term care policy?
No

 

 

Scott@LockwoodLTCSolutions.com
Lockwood Long Term Care Solutions | 253 Melbury Road, Babylon, NY 11702 | (631) 539-7177