Fred Simmons Insurance, Inc.

	LONG-TERM INSURANCE QUOTE FORM

First name
Middle Initial
Last name
Physical Address
City	State
Zip

Mailing Address
City	State
Zip

Home Phone
Work Phone
What is the best time to call you?
Do you want us to call you at an alternative phone number?
Email (required)

Annual Income
Sex	male female
Date of Birth
Occupation
How do you classify your health?
Have you used tobacco in the past 3 years? :	yes no
Do you have any serious health problems? :	yes no (if yes, please explain below)
Health issues known: :
Benefit period desired?
Daily nursing home coverage? (all in dollars)
Do you want coverage for Home Care? :	yes no (If Desired choose daily Benefit)
Desired Daily Benefit (Cannot exceed Nursing Home Benefit)
How many days after care is needed would you like benefits to begin?
Would you like Inflation Guard Benefits? :	yes no
Marital Status?
Spouse's name
Spouse Date of Birth
How do you classify your spouse's health?
Does your spouse have any serious health problems? :	yes no (if yes, please explain below)
Spouse health issues known: :
Has your spouse used tobacco in the past 3 years? :	yes no
Do you currently own a long-term care policy? :	yes no
Add any comments, including any health or concerns you may have:

CA License #OC17932

Privacy notice:
Fred Simmons Insurance Marketing, Inc. insures your privacy. We will include a copy of our Privacy Statement upon request.

This conditional quote is based on the the information you provide(d), and is subject to final approval by the carriers' underwriters.