Insurance Brokers & Consultants

Affordable Insurance Solutions	info@pennhurst.com 215-918-2037

Request a Quote

Professional Liability

Health Insurance

Long Term Care
Insurance

Low Cost Term Life
Insurance

Insurance Information

Professional Liability

General PPO

Benefits of Long Term Care Insurance

Long Term Care Quote Request

Fill in all fields and then click the Submit button to send your request. You can also print out this form, fill it out, and fax it to us at 215-918-2872.

Full Street Address:

City:

State:

Zip Code:

Phone: (Incl. Area Code)

Best Time to Contact You: AM PM

Fax: (Incl. Area Code)

Email Address:

Date of Birth:(ex. 01/01/70 )

Gender: Male Female
Tobacco Use: Yes No

List any present or past conditions such as diabetes, blood pressure, high cholesterol, heart conditions, asthma, or cancer:

Are you currently taking any prescription medications
Yes No

If yes, describe what you are taking the prescription medicine for and whether your condition is under control:

Any hospitalizations or surgery during the past 5 years
Yes No

Daily Benefit:

Select a Daily Benefit amounts from $ 40 a day to $ 200 a day, in $ 10 increments.
$ per day daily benefit

i) Nursing Care Facility - paid up to 100% of your selected daily benefit.
$ per day nursing facility daily benefit

ii) Alternate Care Facility -- paid up to 100% of your selected daily benefit.
$ per day alternate facility daily benefit

iii) Home and Community Care - up to 80% or 100% of your selected daily benefit.
$ per day home and community care daily benefit

Benefit Period
Select the minimum length of time that benefits are available:
2 years 3 years 4 years 5 years

Elimination Period Desired:
7 days 20 days 60 days 90 days

Benefit Account Value
The dollar value of your benefit account is determined as:
Selected daily benefit x Benefit period in days = Your Benefit Account Value

Example: if you choose the $150 maximum daily benefit and a 4 year benefit period, your lifetime maximum benefit would be $150 x 4 years (1,460 days) = $219,000.
Desired Benefit Account Value = $

Insurance Quotes: Professional Liability | Health Insurance | Long Term Care Insurance | Low Cost Term Life Insurance

Insurance Information: Professional Liability | General PPO | Benefits of Long Term Care Insurance