Palffy Insurance Group

Long-Term Care Insurance Quote Request

Long-Term Care Quote Form
*Required Fields

First Name*

Last Name*

Phone Number*

Email Address*

Zip Code*

Birth Date*

Gender*

Tobacco Use*

Height*

Weight*

Do you have a family physician?

When was your last check-up?

How do you perceive your health?

List any medical conditions for which you are currently being treated* (if you don't have any, type "none")

List any medical conditions that you recovered from in the last five years* (if you haven't had any, type "none")

List all medications you are currently taking and daily dosages* (if you don't take any, type "none")

Additional Comments:

A sales agent may call you as a result of submitting this form. We may need to clarify some information while completing your quote request. We may call you to discuss your options after you receive your quote.

The information you provide will only be used to satisfy your quote request. Certain information will be shared with insurance companies for quoting purposes only. No insurance company and no other insurance agency will market to you as a result of submitting this form. We do not share your information with outside organizations for marketing purposes.