LTC Quotes


	Ron Gambardella Insurance & Financial Services 800-685-5727

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Low Cost Life!

Ron Gambardella

Independent Agency

Serving Families Since 1999

www.rongam.com

Long Term Care (LTC) Quote Request Form:

For additional Information please contact our agency today!

Quote Forms: Term Life Permanent Life Annuities Health LTC Group Health

Long-Term Care Request Form

Complete this quick & easy LTC request form and one of our licensed insurance professionals will call you to review your long-term care insurance options.

You may also call our agency direct at 800-685-572.

Who will this quote be for:	**
Marital Status:	**
Your State:	City: **
Choose Your Daily Nursing Home Coverage Benefit:	**
How many days after care is needed would you like the benefits to begin?	**
Benefit Period Desired:	**
Do you want coverage for Home Care?	Yes No **
First Name:	**
Last Name:	**
Contact Phone:	**
Alt Phone:
E-mail:	**
Best time to call:
Birth Date:	Month Day Year **
Sex:	Male Female **
Height & Weight:	(Pounds) **
Do You Smoke or use tobacco?:	Yes No **
In the past 2 years, have you needed assistance with daily activities? ** (explain below) Yes No
In the past 5 years, have you been hospitalized or received in home care? ** (explain below) Yes No
Do you have any health conditions or take any prescription medications? ** (explain below) Yes No
Connecticut Partnership Program?	Yes No
Need Quotes within:
How where you referred to this website:
Additional Health Information or Request:
What is the Waiting Period? The waiting period is the number of days you choose to wait, between the time you file your long term care insurance claim, and the time daily benefit payments begin. What is the Daily Benefit? The daily benefit is the dollar figure that will be paid to an individual on a daily basis for long term care expenses

Investments offered through Jefferson Pilot Securities Corporation, Member SIPC to residents of CT 5 Forest Park Drive, Farmington, CT 06032, Phone: 800 678-7806