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Long Term Care Quote Request

Please complete the following secure form to get your free, no-obligation long-term care quote. If you have any questions as you're filling out the form, please feel free to call Wescom Insurance Services at 1-888-4WESCOM (1-888-493-7266), ext. 1080, Monday through Friday from 8:30 a.m. to 5 p.m. PST.

This is not an application for insurance. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.


Your Information

First Name:
Last Name:
Gender:
Date of Birth:
Email:
Home Phone:
Work Phone:
Fax:
Best time to call:
Address:
City:
State:
Zip:
Weight:
Height:
Are you married? Yes     No Spouse Birthdate
  Self Spouse (if to be covered)
Do you smoke? Yes     No Yes     No
Are you diabetic? Yes     No Yes     No
In the past five years have you:
been confined to a hospital? Yes     No Yes     No
been to a nursing home? Yes     No Yes     No
had home care? Yes     No Yes     No
Do you currently own a long-term care policy? Yes     No Yes     No
Please describe any health problems
Please list your prescribed medications
Comments on your desired coverage
How did you hear about Wescom Insurance Services?
Additional Information: