Florida Long Term Care Insurance Quote

Full Name:
Home Address:
City:    FLORIDA   Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have long term care insurance?
Current Premium:$ per month

Coverage requested for?
Daily Benefit Amount $:
Benefit Period:
Elimination Period:
Payment Mode:

Do you own or rent your primary residence?
What amount do your current assets total?

Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender: Spouse Height: ft. inches     Spouse Weight:
Does your Spouse smoke?
Is Spouse married to Applicant?

Is Spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Additional Comments or Requests

Click on the "Submit Quote Information" button below to send
your Florida Long Term Care Insurance quote request.

We provide affordable Florida long term care insurance quotes to the following
south Florida counties and cities: Miami-Dade County, Broward County, Palm
Beach County, Coral Gables, Kendall, Richmond Heights, Pinecrest, Howard,
Coral Way Village, Westchester, Westwood Lakes, Brownsville, Sweetwater,
Key Biscayne, North Bay Village, Miami Beach, Miami Springs, Virginia
Gardens, Hialeah, El Portal, Miami Shores, Indian Creek, Surfside, Bal Harbour,
North Miami, Biscayne Park, Pinewood Park, Opa Locka, Bunche Park, Hialeah
Gardens, Palm Springs North, Carol City, Miami, Norland, Ojus, Miami Lakes,
Biscayne Gardens, Hallandale, Sunny Isles Beach, Golden Beach, Aventura,
Uleta, Miramar, Pembroke Pines, North Miami Beach, Hallandale Beach, Ives
Estates, Pembroke Park, Hollywood, Dania Beach, Cooper City, Davie, Weston,
Plantation, Playland Isles, Melrose Park, Lauderhill, Sunrise, Tamarac, Fort
Lauderdale, Wilton Manors, Oakland Park, Lauderdale Lakes, Sea Ranch Lakes,
Pompano Beach, Margate, Coral Springs, North Lauderdale, Lighthouse Point,
Hillsboro Beach, Coconut Creek, Deerfield Beach, Boca Raton, The Hamptons,
Highland Beach, Boca West, Delray Beach, Boca Pointe, Boynton Beach,
Lantana, Rainbow Lakes, Atlantis, Lake Worth, South Palm Beach, Palm
Springs, Greenacres, Wellington, Haverhill, Palm Beach, Golden Lakes, Riviera
Beach, Glen Ridge, West Palm Beach, Lake Park, Royal Palm Beach, Jupiter,
Juno Beach, North Palm Beach, Loxahatchee, Belle Glade, Palm Beach Shores,
South Miami, Cutler Ridge, Princeton, Perrine, Naranja, Homestead, Florida City,
Leisure City, Key Largo, Tavernier, Islamorada, Key Colony Beach, Marathon,
Big Pine, Summerland Key, and Key West, FL.

Information received from this south Florida long term care insurance quote form sent to
Insurance Benefit Agency will be for our use only and will not be sold, given to or distributed to
any other parties. A quote will be based on the long term care insurance information provided and
does not guarantee acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as
issued. By submitting this request you acknowledge that this is neither an offer to insure nor a
guarantee of insurance. Completion of this form does not entitle you to Florida long term care
insurance. We are licensed in Florida only and will not provide quotes for other states.