Trahin Miller Insurance Services

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LONG-TERM CARE QUOTE REQUEST
Personal Information
What is your name?
Last
First
Middle
What is your e-mail address?
e-mail
What is your address?
Street
City
State
Zip
What is your telephone number?
Day
Evening
What is your fax number?
Fax
What is your birth date?
Birth Date
What is your gender?
Gender
Male Female
What is your height?
Feet plus inches (example 5'8")
Are you married?
Yes No
 
What is your spouse's name?
Spouse's Name
What is your spouse's birth date?
Spouse's Birth Date
Fill in spouse if spouse is also applying
Self
Spouse
Do you smoke?
Yes No
Yes No
Are you diabetic?
Yes No
Yes No
Are you insulin dependent?
Yes No
Yes No
Do you use a cane?
Yes No
Yes No
Do you use a walker?
Yes No
Yes No
Do you use a wheel chair?
Yes No
Yes No
Do you use any other equipment?
Yes No
Yes No
If you have required assistace with everyday activities in the past 2 years, please explain
In the past 5 years have you:
been confined to a hospital?
Yes No
Yes No
nursing home?
Yes No
Yes No
had home care?
Yes No
Yes No
had long-term care?
Yes No
Yes No
received rehabilitation?
Yes No
Yes No
Please describe your particular health problems
Prescribed medications
Do you currently own a long-term care policy?
Yes No
Yes No
Long-Term Care Quote Selections
Benefit period desired (Average stay in a nursing facility is about 3 years)
Daily Benefit - nursing home coverage  
Daily benefit - home & community care The average cost is $110 per day
How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc? The average cost per month is $3,500 which could be more depending on area of country
Inflation protection/cost-of living adjustment Most needed for younger applicants