FL Long Term Care Insurance Quote

Full Name:
Mailing Address:
City:
Florida
Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:       Cell Phone:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?
Do you currently have long term care insurance?
Current Premium:$ per month

Florida Long Term Care Insurance Coverage Information:

Coverage requested for?
Daily Benefit Amount: $
Benefit Period:
Elimination Period:
Payment Mode:

Asset Information:
Do you own or rent your primary residence?
What amount do your current assets total?

Medical Information:
Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please
provide the necessary information below:

Medication Name:    Dosage:
Frequency:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender: Spouse Height: ft.
Spouse Weight:
Does your Spouse smoke?
Is Spouse married to Applicant?

Is Spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please
provide the necessary information below:

Medication Name: Dosage:
Frequency:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Additional Comments or Requests

Click on the "Submit Quote Information" button below to send your
Florida Long Term Care Insurance quote request.**

**Information received from this Florida Long Term Care Insurance quote request form sent to Landmark Insurance Agency will be for our use only and will not be sold, given to or distributed to any other parties. A quote will be based on the Florida long term care insurance policy information provided and does not guarantee acceptance of the risk by us. The precise coverage afforded is subject to meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By submitting this request you acknowledge that this is neither an offer to insure nor a guarantee of insurance. Completion of this form does not entitle you to a Florida Long Term Care Insurance policy. We are licensed in Florida and will not provide quotes for other states.

Florida Long Term

Care Insurance Quote

Applicant Information:

Have questions about Florida

Long Term Care Insurance?

Click HERE to learn more!

We are a Delray Beach, FL based insurance agency offering affordable
Florida long term care insurance policy quotes in the following cities and
counties: Boynton Beach, Gulf Stream, Boca Raton, Lantana, Rainbow
Lakes, Atlantis, Lake Worth, South Palm Beach, Palm Springs,
Greenacres, Wellington, Haverhill, Palm Beach, Golden Lakes, Riviera
Beach, Glen Ridge, West Palm Beach, Lake Park, Royal Palm Beach,
Jupiter, Coral Springs, Fort Lauderdale, Parkland, Coconut Creek, Margate,
North Lauderdale, Lighthouse Point, Hillsboro Beach, Deerfield Beach, The
Hamptons, Highland Beach, Weston, Plantation, Playland Isles, Melrose
Park, Lauderhill, Sunrise, Tamarac, Wilton Manors, Oakland Park,
Lauderdale Lakes, Sea Ranch Lakes, Villages of Oriole, Pompano Beach,
Lauderdale-by-the-Sea, Boca West, Boca Pointe, Juno Beach, North Palm
Beach, Loxahatchee, Belle Glade, Palm Beach Shores, South Miami, Cutler
Ridge, Princeton, Perrine, Naranja, Homestead, Florida City, Leisure City,
Richmond Heights, Pinecrest, Howard, Coral Way Village, Westchester,
Westwood Lakes, Brownsville, Sweetwater, Key Biscayne, North Bay
Village, Miami Beach, Miami Springs, Virginia Gardens, Hialeah, El Portal,
Miami Shores, Medley, Indian Creek, Surfside, Bal Harbour, North Miami,
Biscayne Park, Pinewood Park, Opa Locka, Bunche Park, Hialeah
Gardens, Palm Springs North, Carol City, Norland, Ojus, Miami Lakes,
Biscayne Gardens, Hallandale, Sunny Isles Beach, Golden Beach,
Aventura, Uleta, Miramar, Pembroke Pines, North Miami Beach, Hallandale
Beach, Ives Estates, Pembroke Park, Coral Gables, Kendall, Dania Beach,
Cooper City, Davie, West Miami, Hollywood, Broward County, Martin
County, Palm Beach County, and Miami-Dade County, FL. We can also
offer Florida long term care insurance quotes throughout the Sunshine state,
including in Miami, Orlando, Tampa, St. Petersburg, Pensacola,
Tallahassee, and Jacksonville, FL.

We can provide affordable Florida Long Term Care Insurance

coverage's in south Florida and throughout Florida!

Landmark Insurance
Agency of Delray Beach,
FL offers affordable and
experienced personal
insurance coverage services
throughout Florida.