New York Long Term Care Insurance Quotes

**Information received from this Long Term Care Insurance quote request
form sent to Insurance Plus will be for our use only and will not be sold,
given to or distributed to any other parties. A quote will be based on the
long term care insurance policy information provided and does not
guarantee acceptance of the risk by us. The precise coverage afforded is
subject to meeting underwriting guidelines, and the terms, conditions and
exclusions of the policy as issued. By submitting this request you
acknowledge that this is neither an offer to insure nor a guarantee of
insurance. Completion of this form does not entitle you to a New York
Long Term Care Insurance Policy. We are licensed in New York and will
not provide quotes for other states.

Full Name:
Home Address:
City:     State:     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have long term care insurance?
Current Premium:$ per month

Coverage requested for?
Daily Benefit Amount: $
Benefit Period:
Elimination Period:
Payment Mode:

Do you own or rent your primary residence?
What amount do your current assets total?

Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please
provide the necessary information below:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender: Spouse Height: ft.
Spouse Weight:
Does your Spouse smoke?
Is Spouse married to Applicant?

Is Spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please
provide the necessary information below:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Additional Information or Comments

Click on the "Submit Quote Information" button below to send
your New York Long Term Care Insurance quote request.**

We are your local Long Island, NY insurance agency, offering affordable
Long Term Care Insurance policy premiums in the following New York
City area cities and counties: Oyster Bay, Huntington, Glen Cove, Port
Washington, Roslyn, Syosset, Jericho, East Hills, Great Neck, South
Huntington, Melville, Pinelawn, Farmingdale, Bethpage, Levittown,
Lindenhurst, Babylon, Bay Shore, Islip, Northport, Hicksville, Westbury,
Mineola, Garden City, Long Island City, Manhasset, Massapequa,
Freeport, Lynbrook, Rockville Centre, Hempstead, Elmont, Valley
Stream, Long Beach, Oceanside, Amityville, Merrick, Bellmore, Jamaica,
Brooklyn, Bronx, Flatbush, Queens, Astoria, and everywhere else in
Nassau County, Queens County, Kings County, New York County,
Bronx County, Westchester County, and Suffolk County, NY.