Request A Long-Term Care Quote

MENUMENU

Request A Quote
Services
About Us
Case Status
Secure Upload
Ask An Underwriter

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.

Contact Us

"*" indicates required fields

Step 1 of 4

25%

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

Phone

This field is for validation purposes and should be left unchanged.

Home
Request a Quote
Services
About Us
Ask An Underwriter
Case Status
Secure Upload
Terms of Use
Privacy Policy

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