Tony Contreras Agency
Professional Service Affordable Price
 
16501 Walnut St., Suite # 1
Hesperia, CA. 92345
(760) 956-3308
(760) 956-3397 fax
CA Insurance License # 0D17792
E-mail:a075236@allstate.com

Our agency is licensed to quote and write insurance policies only in California. To find agents offering these coverages in all other states, please click the IQ.net logo.

  
Long Term Care Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.
   
 Name (required)  
 E-Mail Address (required)  
 Street  
 County  
 City, State, Zip  
 Daytime Phone  
 Night Phone  
 FAX  

 Personal Information
 Sex (required)  
 Date of Birth (required)  
 Height  
 Weight  
 Do you smoke cigarettes (required)  
Occupation   
 Spouse Information
 Sex  
 Date of Birth  
 Height  
 Weight  
 Do you smoke cigarettes  
 Occupation  
 Have either of you ever had any indication of the following medical problems?
 
 Heart disease  
 Cancer  
 HIV  
 Diabetes  
 Cholesterol  
 High Blood Pressure  
 Please explain 'Yes' answers above and any medical problems either of you have had in the last 10 years:
 
 Long Term Care Information
 Coverage type?  

Coverage to begin on what day of nursing home confinement?

 

Amount of daily benefit desitred?

 

Length of Benefit Period ?

 
Available Options 
 Home & Community Care?  
If yes, at what percentage of Nursing Facility Benefit?   
 Guaranteed Future Increases?  
 5% Cost of Living Adjustment?  
 0 year premium payment option?  
 Payment mode desired  
 

 


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Page Created 10/01/2005
 
 
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