Online Quote Request Form For Long Term Care:

Fields marked with an * are required.

Contact Information: 

To what address do you want the quotes and policy summaries mailed and/or e-mailed:

* First Name:
* Last Name:

* Preferred e-mail address: 

* Mailing Address:
* City:
* State:
* Zip:

* Preferred Phone:

Are you currently a member of AAA Carolinas?

Yes No

 

Do you currently own a long term care policy? 

If you already own a long term care insurance policy, and want to compare your current coverage, check this box:     How long have you owned your current policy:  --None-- Less than six months 6 to 12 months 12 to 24 months about 2 to 3 years about 4 years over 5 years

 

Potential Tax Savings:  In order to make you aware of the available tax deductions, tax credits, and tax-favored methods for paying for long term care insurance, please check all the boxes that apply to yourself or to your spouse/partner:

Do you have any type of self-employment income
(either part-time or full-time):

Do you own a Health Savings Account (H.S.A.):

Do you usually itemize your federal tax return:

Do you own your own business?:

Are you (or your spouse/partner) an actively employed (or a retired)
public safety worker (i.e. police officer, firefighter, paramedic):
 

Home Healthcare Benefits: Nearly every long term care insurance policy that can be purchased today will pay benefits for qualified care that you receive in any of the four, main "Care Settings":  nursing homes, assisted living facilities, adult day care, as well as in-home care.  However, some policies pay only 50% to 75% of the benefits when care is received at home. We can design a policy that allows for 100% of the benefits to be used for in-home care.  Check this box if it is important for you to be able to receive as much care at home for as long as possible?:
 

Cost-Sharing:  Check the box at the end of the statement which best describes you:

a)  If I (or my spouse/partner) were to need care sometime in the future and the care cost $100,000 each year, I would be comfortable owning a long term care insurance policy that would pay $85,000 towards the cost of care each year; and I would be able to make up the difference in the cost by using some of my own income and/or some of my own savings.

b)  If I (or my spouse/partner) were to need care sometime in the future and the care cost $100,000 per year, I would prefer to have a long term care insurance policy that covered nearly every penny of the long term care expenses. I would not want to use my own income and/or savings to help pay for the costs of the care. I would be willing to pay a higher premium for a policy like this that more fully covered the costs of care.
 

Current and Future State(s) of Residence:  Not every policy is available for sale in every state.  To make sure we more thoroughly research the various policies available to you, please answer the following questions regarding your state(s) of residence:

What is your primary state of residence: --None-- ALABAMA AL ALASKA AK ARIZONA AZ ARKANSAS AR CALIFORNIA CA COLORADO CO CONNECTICUT CT DELAWARE DE DISTRICT OF COLUMBIA DC FLORIDA FL GEORGIA GA HAWAII HI IDAHO ID ILLINOIS IL INDIANA IN IOWA IA KANSAS KS KENTUCKY KY LOUISIANA LA MAINE ME MARYLAND MD MASSACHUSETTS MA MICHIGAN MI MINNESOTA MN MISSISSIPPI MS MISSOURI MO MONTANA MT NEBRASKA NE NEVADA NV NEW HAMPSHIRE NH NEW JERSEY NJ NEW MEXICO NM NEW YORK NY NORTH CAROLINA NC NORTH DAKOTA ND OHIO OH OKLAHOMA OK OREGON OR PENNSYLVANIA PA RHODE ISLAND RI SOUTH CAROLINA SC SOUTH DAKOTA SD TENNESSEE TN TEXAS TX UTAH UT VERMONT VT VIRGINIA VA WASHINGTON WA WEST VIRGINIA WV WISCONSIN WI WYOMING WY
Is there a second state in which you regularly reside?: --None-- ALABAMA AL ALASKA AK ARIZONA AZ ARKANSAS AR CALIFORNIA CA COLORADO CO CONNECTICUT CT DELAWARE DE DISTRICT OF COLUMBIA DC FLORIDA FL GEORGIA GA HAWAII HI IDAHO ID ILLINOIS IL INDIANA IN IOWA IA KANSAS KS KENTUCKY KY LOUISIANA LA MAINE ME MARYLAND MD MASSACHUSETTS MA MICHIGAN MI MINNESOTA MN MISSISSIPPI MS MISSOURI MO MONTANA MT NEBRASKA NE NEVADA NV NEW HAMPSHIRE NH NEW JERSEY NJ NEW MEXICO NM NEW YORK NY NORTH CAROLINA NC NORTH DAKOTA ND OHIO OH OKLAHOMA OK OREGON OR PENNSYLVANIA PA RHODE ISLAND RI SOUTH CAROLINA SC SOUTH DAKOTA SD TENNESSEE TN TEXAS TX UTAH UT VERMONT VT VIRGINIA VA WASHINGTON WA WEST VIRGINIA WV WISCONSIN WI WYOMING WY
 

All of the policies we'll quote for you will pay benefits for qualified care you receive anywhere in the United States (although some benefits may be specific to certain states). Also, some policies can pay benefits for qualified care received outside the U.S., while other policies will only pay benefits for care received inside the U.S.  Check the box if you think you might move to another state or another country in the foreseeable future?:

To help you plan better for your future care needs, please specify the state(s) and/or country in which you might reside in the foreseeable future:
 

 

Family Caregiving Options:  It is common for family members to care for their loved ones, if not on a full-time basis, at least periodically. Which statement best describes your goals regarding your future care needs:

I would prefer to design my long term care insurance policy so that it should provide enough benefit so that I would not have to rely on friends and/or relatives to provide some of my care for free?:

-OR-

I want to design my long term care insurance policy with the expectation that some of my care will be provided for free by friends and/or relatives?:

About how often do you anticipate your family member(s) could provide your care: --None-- 1 day per week 2 days per week 3 to 4 days per week 5 to 7 days per week Unsure

About how many hours per day do you anticipate your family member(s) could provide your care?:

Not all long term care policies will pay for a family member to care for you.  If it is important for you to have a policy that would actually pay a family member to provide some of your care for you, then check this box here:

Since only some long term care policies will pay for a family member to care for you, are you willing to pay a higher premium for a policy that would pay a family member to provide care for you?: --None-- No Yes
 

Future Costs of Care:  As the demand for care has increased, long term care expenses have risen significantly. Care that currently costs $80,000 per year, is projected to cost almost $200,000 per year 20 years from now.

Is it important for you to have a long term care policy that will grow each year to try to keep pace with the increasing costs of care?  If so, check this box here:
 

 

Inflation Increases:  Nearly every  long term care policy has some type of feature to help protect you against the increasing cost of care.  There are 2 main types:

Type 1:  Some policies are designed in such a way that the premium starts off lower and then the premium goes up 5% or more each year as the benefits increase each year.  The benefits in these policies double about every 15 years.  This type of policy can double in cost about every every 12 to 15 years.

Type 2:  Other policies start off with higher premiums now, but the benefit increases are automatically built into the premium. With this type of policy, the increases in the benefits each year do not make the premium go up each year.


Check the statement which best describes you:

(Type 1)  I would prefer a policy that starts off with a lower premium now and have the premium increase each year by 5% or more, as the benefits increase each year:

-OR-

(Type 2)  Even though it starts off with a higher premium now, I would prefer a policy that has the inflation benefits built into the policy from the beginning. This way I will have a more stable and a more predictable premium over a longer period of time:
 

 

Protection of Your Assets or Income:  Please check all that apply. 

Is it important for you to protect your assets or your income for:

A disabled child or relative:
Charitable organizations:
Your own financial independence:
The financial independence of your spouse or partner:
Your heirs

If it's not important  for you to protect your assets or income, check this box:
 

 

Lifetime Maximum Benefit (Policy Limit):  Nearly every type of insurance policy has some kind of "Policy Limit". Your homeowner's insurance, your auto insurance, and even your medical insurance, has some kind of "Policy Limit". 

With long term care insurance, you can choose to have a policy with a "limit" or you can choose a policy that has "no limit". Of course, a policy with "no limit" is more expensive than the same policy with a limit.

What's unique about long term care insurance is that your policy limit grows each year according to the Inflation Benefit that you choose for your policy. For example, you might choose a policy with a starting limit of $250,000 and a 5% Compounded Automatic Inflation Benefit. The policy would start off with a $250,000 Lifetime Maximum Benefit, but it would grow to over $500,000 within 15 years and continue to grow to over $1,000,000 worth of benefit within 30 years.

About how much do you think you'd want your starting policy limit to be?: --None-- Not Sure $200,000 $250,000 $300,000 $400,000 $500,000 $750,000 $1,000,000 Unlimited (no limit)
 

 

Your Thoughts about Long Term Care Insurance:  Which of these statements most accurately describes your thoughts on long term care insurance?

a)  I've decided that long term care insurance is definitely right for me and I plan on purchasing a policy within 3 months or so. Right now I'm looking for information to help me choose the policy that's best for me:

b)  I'm not sure if long term care insurance is right for me. To help me decide, I want to see what kind of benefits are available and at what cost.:

c)  Right now I want some information about costs and benefits so that I can better plan on when to move forward with a policy. It will probably be at least six months to a year before I plan on purchasing the policy.:
 

If there are any other matters which are important to you in designing and choosing your long term care policy, please share that information in the box below.  Enter any additional details about what benefits you want included in your long term care insurance policy, including any features or benefits that you consider important.  Also feel free to enter your thoughts regarding: daily benefit, inflation benefit, benefit period, elimination period, care settings, financial ratings, premium rate stability, etc...:

 

 

 

Health Questions for Yourself:
In order for me to get you the best possible rates, please answer the following health questions for yourself.  If you would prefer to go over the health questions over the phone, then scroll to the bottom of the page and hit the 'Submit' button.  I will call you within 1 business day and go over these health questions with you over the phone.

What is your Date of Birth (MM/DD/YYYY): 

List your prescription medications below:

List the reason(s) for which each of your medications has been prescribed:

What is your height: --None-- 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11" 7'0"

What is your weight:

Approximately, what was your weight this time last year:

What is your history of tobacco use: --None-- Never used No tobacco use in over 5 years No tobacco use in over 3 years No tobacco use in over 12 months Celebratory Cigar Use Currently smokes cigarettes Currently uses other types of tobbaco (not cigarettes)

Please provide as much detail as possible in the boxes below if you have been treated for any of the following conditions in the past 10 years:

Stroke, C.V.A or T.I.A. (mini-stroke):

Any type of cancer (except basal cell skin cancer):

Any type Hepatitis:

Any type of Heart Disease:

Any type of of Diabetes:

Any injuries from falls or any broken bones or fractures:

Any surgery or hospital stay (not previously mentioned):

Any chronic illness or any other illness not yet mentioned:

If you have received any type of disability benefits in the past 5 years,
please check this box: 

 

Many insurers offer discounts of 20% to 40% when married couples or domestic partners apply together for long term care insurance. 

If you are married or have a domestic partner and you want your quotes to include coverage for your spouse/partner, please answer the health questions for your spouse/partner.

 

Health Questions for Your Spouse/Partner:

What is the name of your spouse/partner:   

What is his/her Date of Birth (MM/DD/YYYY):
 

List his/her prescription medications below:

 

List the reason(s) for which each of his/her medications has been prescribed::
 

What is his/her height (approx.): --None-- 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11" 7'0"

What is his/her weight (approx.):

Approximately, what was his/her weight this time last year:

What is his/her history of tobacco use: --None-- Never used No tobacco use in over 5 years No tobacco use in over 3 years No tobacco use in over 12 months Celebratory Cigar Use Currently smokes cigarettes Currently uses other types of tobbaco (not cigarettes)

 

Please provide as much detail as possible in the boxes below if your spouse/partner has been treated for any of the following conditions in the past 10 years:

Stroke, C.V.A or T.I.A. (mini-stroke):


Any type of cancer (except basal cell skin cancer):


Any type Hepatitis:


Any type of Heart Disease:


Any type of of Diabetes:


Any injuries from falls or any broken bones or fractures:


Any surgery or hospital stay (not previously mentioned):


Any chronic illness or any other illness not yet mentioned:


If your spouse/partner has received any type of disability benefits in the past 5 years,
please check this box:

Click on the "Submit Query'' button and we will get to work on your long-term care insurance quote comparisons.  We will have them completed within 1 to 2 business days.

Sincerely,

L. Wayne Keith
E-mail:  lwkeith@thekeithagency.com
Toll-free:  1-800-328-9425