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189 Route 100, Somers NY 10589
914-277-2227
914-401-9320
jay@gerlitzgroup.com
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Quote Forms
Long Term Care Quote
Long Term Care Quote
Name
Please fill out your contact information on page 1 and then information pertinent to your long term care quote on page 2.
First Name
*
Last Name
*
Street Address
City, State, and ZIP
Email address
Phone Number
Best Time(s) to Reach You
Morning
Midday
Afternoon
Evening
Weekdays
Weekends
Anytime
Self
Name
Date of Birth
Gender
Marital Status
Height
Weight
Please Complete this Section for Yourself.
Do you smoke?
Yes
No
Are you diabetic?
Yes
No
Are you insulin-dependent?
Yes
No
Do you use a cane?
Yes
No
Do you use a walker?
Yes
No
Do you use a wheel chair?
Yes
No
Do you use any other equipment?
Yes
No
If you have required assistance with everyday activities in the past 2 years, please explain.
In the past 5 years have you:
Been confined to a hospital?
Yes
No
Been confined to a nursing home?
Yes
No
Had home care?
Yes
No
Had long-term care?
Yes
No
Received rehabilitation?
Yes
No
Please describe any health problems you have.
Prescribed medications:
Do you currently own a long-term care policy?
Yes
No
Please Complete this Section for your Spouse.
Do they smoke?
Yes
No
Are they diabetic?
Yes
No
Are they insulin-dependent?
Yes
No
Do they use a cane?
Yes
No
Do they use a walker?
Yes
No
Do they use a wheel chair?
Yes
No
Do they use any other equipment?
Yes
No
If they have required assistance with everyday activities in the past 2 years, please explain.
In the past 5 years has your spouse:
Been confined to a hospital?
Yes
No
Been confined to a nursing home?
Yes
No
Had home care?
Yes
No
Had long-term care?
Yes
No
Received rehabilitation?
Yes
No
Please describe any health problems you have.
Prescribed medications:
Do you currently own a long-term care policy?
Yes
No
Long-term care quote selections:
Benefit period desired:
Select
2 Years
3 Years
4 Years
5 Years
6 Years
Lifetime
(Average stay in a nursing facility is about 3 years)
Daily benefit - nursing home coverage
Select
Not sure
$0
$40 - $100
$100 - $150
$150 - $200
$200 - $250
$250 - $300
$300 - $250
$350 - $400
Daily benefit - home & community care
Select
Not sure
$0
$40 - $100
$100 - $150
$150 - $200
$200 - $250
$250 - $300
$300 - $250
$350 - $400
How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?
Select
0 mo.
1 mo.
2 mo.
3 mo.
4 mo.
5 mo.
6 mo.
Up to 1 year
Not sure
The average cost per month is $5,000 which could be more depending on area of country
Inflation protection/cost-of living adjustment
Select
No increase wanted
Simple - 5% each year
Compounded - 5%
Most needed for younger applicants
Comments or Questions?
No coverage of any kind is bound or implied by submitting information via this online form We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others. By completing this form, you are acknowledging your understanding of and agreement with these terms.
