Adam Miller Agency Home Page About Our Staff Our Newsletter

Auto Quote 
Business Quote 
Contractor General Liability Quote 
Disability Quote 
Employee Practices Liability Insurance 
Group Health Quote 
Health Quote 
Home Quote 
Life Quote 
You Are Here! 
Cycle Quote 
Workers Comp Quote 
Service Request 
Claim Form 
 

      

Long Term Care Insurance Quote Request Form

Please fill in the information below to receive a Long Term Care Insurance quote for Connecticut.

Our insurance agents will provide a quote for insurance as soon as possible.

Name and full address including zip code are required.  All other information is optional although the more you provide, the more accurate the quote.

For fastest response please include email address. 

Name:      
Address:    
           
City:       CT
Zip Code:  
Phone #:      
Fax #:     
Email:      
Prospects Name:   
Date of Birth:  
Height:            
Weight:         
Gender:            Female Male
Occupation:     

Does prospect smoke? Yes No

Prospect's Medical History

Does the prospect have any history of:

Cardiovascular (Heart) Disease? Yes No

Cancer? Yes No

Cholesterol Problems? Yes No

Has the prospect had, or currently have, or has ever been medically 
diagnosed as having:

Diabetes under treatment with Insulin; Alzheimer's Disease; Organic 
Brain Syndrome; Dementia; Memory Loss; frequent or persistent 
Forgetfulness; or Senility? Yes No

Multiple Sclerosis; Parkinson's Disease or Stroke? Yes No

Does the prospect need the assistance of or supervision by another
person in performing any of the following activities:

Moving in/out of bed or chair; Bathing; Dressing; Eating;
Walking? Yes No

Other Medical Problems? Yes No

Have you ever applied for Long Term Care Insurance which resulted in 
your being turned down, asked to pay extra premium or issued 
with a rider or exclusion? Yes No

Requested Daily Benefit Amount : 

Please list any details for any questions answered yes above.

Current Coverage

 
Do you currently have Long Term Care Insurance? Yes No

If yes, with what company?

Additional Information or Comments

We appreciate you taking the time to tell us how you came to our Web site...

If you don't find it in the list above, enter here... 

   
The resulting quote does not constitute coverage and is subject to
verification by the insurance company.