LTC Insurance Application Request

Before you fill out this form make sure you have received a quote first because we represent different companies and need to know which application to send you. (get a quote)

If you just want to get a ballpark idea of the cost go to QuickQuote.

States require paper applications to be filled out and submitted, online applications are not yet available for long term care insurance.

After you have prequalified and received a quote you can request an application by filling out this form. We need you to prequalify before applying to make sure you are insurable, we don't want to waste your time. If you are uninsurable we have other options for you.

After you fill out the form below we will email or mail your application (your choice) with instructions, and we have phone support if you need assistance with the forms. The application sent will be based on the company with the lowest premium for your age and state.

At this stage you are only applying for approval and are not committed to the insurance or to the benefits of the plan. Approval takes 3-6 weeks. Once approved you will be sent a policy proposal and have by state law 30 days to keep it, change it, or cancel it.

Please fill out the entire form. We do not sell or share your information.

Since we represent all the major long term care insurance carriers without preference the premiums are the same if you buy your insurance through us or somewhere else. We will provide you with the lowest premiums for the benefits you select.