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Click here for Information on Long Term Care Insurance from our Customer Center
We value your inquiry into Long Term Care Insurance with The Compass Insurance Group.
This seems informal gathering this information to provide you a quote. We want you to know that we look forward
to meeting you and discussing your unique needs.
This product and the companies we represent and my company all believe relationships are critical.
We will be in touch with you soon.
First Name:
Last Name:
Age/ D.O.B.
Residence State:
Smoker?
Select one:
Yes
No
Health Summary:
Spouse/ Dom. Partner First Name:
Spouse/D.P. Last Name
Spouse/D.P. Age & D.O.B.
Spouse/D.P Residence State
Spouse/D.P. Health Summary
Spouse/D.P. Smoker?
Select One:
Yes
No
Email Address:
Phone Number:
Best Time to reach you:
Benefit Period
Select one:
2
3
4
5
6
10
Lifetime
Elimination Period
Select One:
30 days
60 days
90 days
180 days
365 days
Selection List
Benefit Options
Select One
Daily
Monthly
Enter Daily Benefit Options:$50 to $500 in $10 incements:
Enter Monthly Benefit Amount: $1500-$15000 in $100 increments:
Inflation Options:
Select One:
CPI Compound
5% Compound
5% Simple
GPO Guarenteed Purch. Option
None
Do not enter anything in this field:
