ALLiS Login | phone icon (877) 254-4429

Quote Request: Long Term Care

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential: please see our Privacy Policy. Please do not hit "Enter" or click "Send Quote Request" until the form has been completed. For serious health problems or unusual circumstances, please call (toll free) 877-254-4429 for a no-cost, confidential consultation. *Red = Required Field.

Advisor Information

Proposed Insured

Contact Information

Current Address

Household Information


Health Details

Have you EVER been diagnosed with, treated for, hospitalized for or been advised to seek treatment for:

Example: Diagnosed with elevated blood pressure 2 years ago – take 20 mg Lisinopril daily – last reading 128/82

Example: High Cholesterol – July 2014 – take Crestor 20mg / day – had physical in May – readings were great

Cancer Type 1

Example: Nightly use of CPAP

LTC Coverage

Home Care Benefit is 100% of Nursing Home Benefit

Individual Policy 1

Tobacco/Nicotine Type 1

Example: 1 pack daily

** Please have your spouse/partner complete his/her own quote request.

Delivery Options

Additional details you'd like to include to help us with the quote.