Kleinschmidt Insurance—Long-Term Care Insurance Quote Request

QUOTE FORMS

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CLAIMS

Please complete this form as completely and accurately as possible and submit it to us when you are finished. If you wish, you may also print out the form and fax it to us (734•662•5379) or call our office with this information.

Note that we cannot provide coverage until a policy or binder has been issued by the insurance company. As part of our quoting process, we may need to verify some information such as credit history, prior insurance history, and financial stability information.

Contact Information
Name:
Street address:
City:
State:
Zip code:
County:
Phone (home):
Phone (work):
Fax:
Email address:
Quote Information
Birth date (mm/dd/yy): Gender: Male Female
Ht. (ex. 5'8") Wt. (ex. 150 lbs) Smoker: Yes No
Daily benefit ($50–$500): Waiting period in days (0–365):
Benefit period: Lifetime 3 years or more 12 to 35 months	Include home health care coverage? Yes No Include compound inflation rider coverage? Yes No
Please describe any and all conditions that resulted in hospitalization and/or surgery in the past 10 years:
Spouse/Companion Information
Relationship: Spouse Companion
Name:
Date of birth (mm/dd/yy): Gender: Male Female
Additional Considerations/Requests
Please add any additional comments you feel appropriate for this quotation.