LONG TERM CARE QUESTIONNAIRE

Complete the form and click "Submit Request" for a free Long Term Care insurance quote.  The accuracy of the quote you will receive will depend on the information provided. If the information provided is incomplete or incorrect, your actual cost may change. We will review the information with you when the final application is prepared.  Please also read our Privacy Statement.

NOTE: You do not need to be a credit union member to obtain a quote.

 * = required field
* Full Name: * Date of Birth:
* Height:   * Weight:    * Are you a smoker?   Yes No  
Are You Married: YesNo      NOTE:  If you are married, you may be eligible for some premium savings if you and your spouse are written together. --- If so, please complete and submit this questionnaire for each person and tell us you are doing so in the comment section at the bottom of  this form.
1. * Are you currently taking any medication? Yes No
 

If yes, please list all medications, the dosages (if known), and the conditions you are taking them for.

2. Have you been hospitalized within the last 5 years? Yes No
 

If yes, please list the dates and conditions you were hospitalized for.

3. * Have you seen a specialist within the last 5 years? Yes No
  If yes, please list the dates and condition you saw a specialist for.
4. Have you ever been diagnosed or treated for any of the following?
 

Cancer Alzheimer's Dementia Multiple Strokes Multiple Sclerosis Incontinence
Diabetes 100+ units of insulin Muscular Dystrophy Emphysema & Current Smoker

* Your Phone: * Your email:
(please verify that you entered your email address correctly)		 * Your Town:

* With which Credit Union do you do business? (Affiliated credit unions benefit when members and friends use Equinox services.)
Please Read
In order to provide a policy quote some of the companies that we represent may require additional information.  We treat all information that you provide as confidential and that information will be used only for insurance purposes.
By submitting this form, you acknowledge that you have been informed and understand that insurance products offered through Equinox, F. A. Peabody Company, or any affiliate credit union are NOT insured by the NCUA.
You understand and agree that the information gathered here will be used by Equinox Insurance to review your insurance program, send quotes and recommend insurance purchases. You acknowledge that you do not have to accept the quote offered. You have a free choice of insurance agency. You also acknowledge that purchasing or not purchasing insurance from Equinox will not in any way affect any loan decisions.
 

Print this Page for your reference.

 
 

The information you have provided will be kept confidential and will only be used to obtain quotes for your insurance.  Someone from Equinox Insurance will contact you shortly.