Your Contact Info

First Name Last Name

Home Address? (street, city, zip)

Email

Your Phone Number?

Best Time to Call? AM PM any time

Would you like us to telephone or email you with the quote?

Telephone Email

Policy Requirements

Daily benefit ($) requested: (note: the average Boston area nursing home costs $300 per day)

Number of years benefit will last (2,3,4, 5 or lifetime)?

What is the waiting period (number of days you will be self-insured)?
0
30
60
90

Rate at which home health care will pay benefits.

50% 75% 100%

Tell us about yourself

Occupation and Employer? (or former, if retired)

Date of Birth (month/date/year )

Married? Yes No

Will your spouse also be applying for Long Term Care Insurance? (Many companies offer substantial discounts when both spouses apply) Yes No

Your height? (feet and inches)

Weight? (lbs)

In the past five years, have you ever used tobacco or any other product containing nicotine?
Yes No

If you have quit, please give the date you most recently used.

Please list all physical and mental health conditions for which you have been treated, or recommended to get treatment, in the last 6 years: (please list Condition, Treatment, Date(s) treated and Degree of Recovery.)

Please list all medications currently being taken: (Condition treated, medication name and milligrams, dosage per day, date first prescribed).

Where possible, we will quote 2 companies which best fit your underwriting profile

How did you hear about Beacon Insurance?

Web search Print Ad Local Yellow Pages

If a friend, what's their name?

If an agent, please list the agent's name here