Long Term Care Quote Form
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Your Information:
Your Name:* 
Address: 
City/State/Zip Code:*
Phone: 

Fax: 

Email:*   

Date of Birth: 
Sex:   Male  Female
Height:  Weight: 
Long Term Benefits Desired:
I am interest in:  
I want Benefits to begin:       Length of benefit period  
Tell us about your health:
How is your health (check one): 
Excellent (Trim and no medications) 
Good (No infirmity or medications) 
Fair (Taking medication or overweight) 
Poor
(Describe health or activity problem {ie.drugs or alcohol} in "Other comments") 
I have been diagnosed or treated for the following health conditions: 
      (Please check all that apply.)
Arthritis
Alzheimer's
Anemia
Asthma
Aids or Aid Related Condition
Brain or Nervous System Disorder
Chest Pain
Connective Tissue Disorder
Cancer
High blood Pressure
Depression, Schizophrenia or
       other Mental Illness Disorder
Diabetes
Emphysema
Gastrointestinal or Endocrine
       System Disorder
 Heart Attack
Heart Murmur
Heart or Vascular System Disorder
Hemophilia
Hepatitis
High Cholesterol or Glucose
Liver or Kidney Disorder
Lung or Respiratory Disease or Disorder
Malignant or Benign Growth
Musculoskeletel Disorder
pneumonia
Seizures
Stroke
Tuberculosis
Tumor or Mass Growth
None of the above
Have you ever used any tobacco or Nicotine products?
Yes No  
If yes: Are you currently using? Or, when did you quit?
Currently Uses Quit . 
The date you quit:  (month and year)
Comments questions and suggestions:
Other comments/questions: 

This page is provided as a service to you. It is not possible to bind any new coverage from this request. If you have NOT received your confirmation from us within 24 hours the same or next business day, please contact us. NO COVERAGE IS CONSIDERED BOUND UNTIL YOU RECEIVE OUR CONFIRMATION. Thank you for your understanding.
    

  Thank you for completing our form.
We welcome the opportunity to serve you.
Ramsey Insurance Agency
CA Ins. License #0490642

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