Mark Garetz, CSA
Insurance Specialist
Certified Senior Advisor

Life Insurance - Health Insurance - Annuities - Long-Term Care Insurance - Disability Insurance - Homeowners Insurance - Auto Insurance

Serving the Tri-Valley Area: Danville, Blackhawk, San Ramon, Dublin, Pleasanton, Alamo, Walnut Creek and Livermore

 

 

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Long-Term Care Insurance Quotes

Please fill out the following information to the best of your ability.  The more accurate this information is, the more accurate a quote I'll be able to give you.  Many agents believe that the way to get your business is to "low-ball" you by giving you a quote that's well below what you would actually get when you receive the policy.  They do this by rating you in the highest category such as "super preferred" regardless of your real rating (which depends on your height, weight, medical history, etc.).  I don't play this game.  I always try to get you the most accurate quote possible so there are no surprises later.

* denotes a required field

Your First Name:*    Your Last Name:*

Your street address:*

Your city:*   Your State:*   Your Zip Code:*

Your daytime phone number:*

Your evening phone number:

Best time to call (if necessary): Anytime  Morning Afternoon  Evening

Your email address:*  

Your email address:*   (retype)

Do You Currently Have Long-Term Care Insurance?: Yes  No

If yes, who are you currently insured with?:

Are you a:  Male  Female *

What is your birth date?* (mm/dd/yyyy)   /     /  

Height:*    Weight:* 

Daily Benefit Desired? * 

Do you want inflation protection (5% annual increase)?  Yes  No Compound?

Length of benefit desired?*

Time before benefits start?*    (longer time = lower premium)

When did you last use any tobacco products?*

What is your blood pressure (if you know it)?   / 

Are you taking any medications to control your blood pressure? No  Yes

What is your cholesterol level (if you know it)?

What is your Cholesterol/HDL ratio (if you know it)?:

Are you taking any medications to control your cholesterol?  No  Yes

Is there any family history of cardiovascular disease before the age of 60? No    Yes

Have you ever had cancer? No  Yes

Any other comments or questions?


No High Pressure, Ever!

2248 Camino Ramon
San Ramon, CA  94583
866-277-7544
CA License #0E08278