Lifetime Insurance Services, Inc.  
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Long-Term Care Insurance Quote Request

Just fill in the simple form below and a representative will contact you shortly with a personalized quote.

Please provide the following information.
Long Term Care Options
Daily Benefit
How much the policy pays out per day for nursing care or home health care is the Daily
Benefit.
Benefit Period
The length of time for which a policy will continue to pay the benefits associated with
long-term care is the Benefit Period.
Elimination Period
With most policies, your benefits won't start the first day you go to a nursing home
or start using home care. During an Elimination Period, the policy will not pay the
cost of long-term care services.
Inflation Protection?
There is an option with most plans called an Auto Inflation Rider, available at an
additional cost, which increases the benefits according to the rises in inflation. For Texas
consumers, compound protection must be rejected before other forms are considered.
Nonforfeiture Benefits No Yes
Nonforfeiture benefits in policies, available at an additional cost, provide that at least some
benefits will be paid even if the buyer fails to keep up premium payments and the policy is
cancelled for non-payment.
Preferred Payment Mode Annual Semi-Annual Quarterly Monthly
The Payment Mode indicats whether you want to pay for the insurance once a year
(annually), semi-annually, quarterly or monthly. When not paying annually there is
usually an additional administration fee.
Name (first, last)*   
Street Address
City
State*
Zip
Phone*
Email*
Birth Date*
Gender
Current height and weight? ft  in     lbs
Tobacco?
Have You Been Hospitalized? No Yes (Within Last 5 Years)
If yes, why?
Current medications and reason?
Other medical conditions?
Include Spouse (check box if you are interested in a joint quote with your spouse)
Please enter your contact information if different from above:
Contact Name
Contact Phone
Contact Instructions
Answering the questions on this page will not result
in a determination of your eligibility for coverage.