Thanks for taking to time to submit your long-term care quote.  The information will be submitted to our offices and we will contact you real soon.  The information is said confidential and will be used for quote information only.  We look forward to being your agent/agency.

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Date of birth	January February March April May June July August September October November December
Birth Date	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year Born
Height
Weight
Smoke tobacco	Yes No
What is your daily benefit? ($50 - $500)	$50 $60 $70 $80 $90 $100 $200 $300 $400 $500
What is your waiting period? (0 - 365 days)	0-30 31 -100 101 - 200 201 - 300 301 - 365
What is your Benefit Period	3 years or more 12 to 35 months lifetime
Do you want home health coverage included	Yes No
Do you want inflation rider coverage included	Yes No
Tell us about any and all of your health conditions
Please list all of the prescribed medications that you are currently taking, the dosage amount your said diagnosis and frequency
Relationship:	Spouse Companion
Name
Gender	Male Female
Date of Birth - Month	January February March April May June July August September October November December
Birth - Date	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Disclaimer:

We will be discussing a few said coverages, while visiting our site, but they are for illustration and informative purposes only and not an statement of contract of a said contract.  Remember all insurance has its guidelines.  Our website also has links to other similar businesses and are no way able to control its said content nor what its affiliates,subsidiaries convey. Our firm is based on professionalism and integrity.  If there is anything that offends you while visiting our site, please contact us. Our business is about being informative and helping you the consumer make better said choices when it comes to your insurance.  Contact us: j.barnes@theemerginginsuranceagency.com.

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