LONG -TERM CARE INSURANCE

Planning is crucial…

The advisors at Freedom Financial will meet with you for a FREE one-hour consultation. Your advisor will consider any current needs and circumstances, your budget, as well as your future goals for protection against the expenses of long-term medical care.
   

After assessing your needs and goals your advisor will then design a plan customized for your specific situation that will provide the best protection for you and your loved ones.

If you would like a complimentary consultation or receive information you need to determine if long-term care insurance is appropriate for you and your family, please take a moment to complete the information request form below.
 

Information for Long-Term Care Insurance

This site employs strictly confidential email. Your name and information will NOT be given out to ANY mailing lists.

GENERAL INFORMATION
All fields in RED are required

Your Name:

Date of Birth: mm/dd/yy

Spouse's Name:

Spouse's Date of Birth: mm/dd/yy

E-Mail Address:

Street Address:

City:

State: Zip Code:

Contact Phone Number:

How did you find this web site?

Best Time to Call: Morning Afternoon Evening

Please tell us your main reason for seeking coverage for long-term care?

Do you currently own a long-term care policy that you would like to compare with other plans available? Yes No
If yes, List carrier and Year purchased:

Health Information
Please answer the following quick questions to help determine your eligibility for long-term care insurance. Depending on your health, you may or may not be eligible for long-term care insurance. Your health does not have to be perfect; however, there are certain conditions that would prevent you from being considered for long-term care insurance.

In the past 5 years, have you or your spouse used tobacco products including cigarettes, pipe, cigar or chewing tobacco?
You: Yes No Spouse: Yes No

During the past 10 years, have you been confined to a hospital, nursing home, received home care or diagnosed or treated for any serious condition?
You: Yes No Spouse: Yes No
If you or your spouse answered Yes, please describe:

Please list all medications you are currently taking and what they're for.
You:

Your Spouse:



 


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