Request A Long-Term Care Quote

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Protecting your client’s income by providing nursing home care, home health care, personal or adult day care for individuals with a chronic or disabling condition that needs constant supervision.

Use the form below to request a personalized quote for your client. We're on your side, so if you have questions along the way, please contact us.

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Long-Term Care Quote

Broker Name*

Date*

MM slash DD slash YYYY

Email*

Phone*

Primary Insured Name*

First Last

State*

Date of Birth*

MM slash DD slash YYYY

Gender*

Height / Weight (if known)

Tobacco Use*

Medications & Medical Conditions (if known)

Been declined, rated, or postponed? **

If yes, please provide details:*

Spouse Information

Spouse Applying*

Spouse Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Gender*

Height / Weight (if known)

Tobacco Use*

Medications & Medical Conditions (if known)

Coverage Information

Amount Requested or Maximum Available?*

Benefit Payout Method*

Benefits Frequency

Daily

Monthly

Elimination Period

0 Days

30 Days

60 Days

180 Days

365 Days

Benefit Period

2 Years

3 Years

4 Years

5 Years

6 Years

Share Care

Inflation

Special Rider Requests

Approximate Target Premium

Date Needed

MM slash DD slash YYYY

Finish & Send

Additional Remarks

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Berkshire Advisor Resource, Inc.
An Income Protection Resource Group Company
136 Capano Crk
Boerne, TX 78006
Phone: 303-221-2100
Toll-Free: 800-530-2360