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On-Line Long Term Care
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Personal Data

Your Name:
Street Address:
City:
State: (Must be Georgia)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Are You Looking For
Spouse Coverage?
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Health Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

UNDERWRITING INFORMATION
 
Insured Name: Birthdate:
Insured Height: Insured Weight:
Insured Occupation: Sex (M/F):
 
Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!
Do You use tobacco? Yes No Describe usage (cigar, cigarettes, etc.)
 
Any Pre-existing Health Conditions?
 (If yes, descibe in detail, and to which of the insured persons they apply.)
 
Any Covered Persons Currently Taking Medication of Any Kind?
 (If yes, descibe in detail, and to which of the insured persons they apply.)

COVERAGE INFORMATION
 
How Long Do You Need Coverage For?
(1 Year, 5 Years, Lifetime, etc.)
 
What Daily Benefit Amount Needed? (In Dollars $)
 
What Waiting Period Do You Want?
(30 days, 60 days, 90 days, etc.):
 
Any special coverages needed?
(Such as Home Health Care Cov., Compound Inflation Rider, etc.)
 
Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:

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James M. Swain & Associates, Inc. . PO Box 365 . Baxley, GA 31515
Toll Free: 800-870-5830 . Local Phone: 912-367-3601 . Fax: 912-367-7152
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