First Person's Information:

Desired Insurance:
Daily benefit $25 $30 $35 $40 $50 $60 $70 $80 $90 $100 $120 $140 $160 $180 $200 >$200 Don't know Elimination Period 0 day Facility Care/ 60 Day Home Care 90 day Facility Care / 90 Day Home Care Maximum Length of Claim 1 year 2 years 5 years Life Don't know

Optional Benefits:
Return all premiums if you never claim:
Maintain daily benefit with cost of living:
Future Purchase Option:

Birthdate: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Vital stats:
Gender Male Female Height <4'10'' 4'10'' 4'11'' 5'0'' 5'1'' 5'2'' 5'3'' 5'4'' 5'5'' 5'6'' 5'7'' 5'8'' 5'9'' 5'10'' 5'11'' 6'0'' 6'1'' 6'2'' 6'3'' 6'4'' 6'5'' 6'6'' 6'7'' 6'8'' >6'8'' lbs. Tobacco Use None, Ever None in 5 years None in 3 years None in 1 year Pipes / Cigars Cigarettes Patch/gum

Are you or is he/she currently a resident of Canada?

Ever been declined insurance or offered nonstandard rates?

Are you or is he/she currently taking any medications?
If yes, please describe Medical situation:

2nd Person's Information:

Desired Insurance:
Daily benefit $25 $30 $35 $40 $50 $60 $70 $80 $90 $100 $120 $140 $160 $180 $200 >$200 Don't know
Maximum length of claim 1 year 2 years 5 years Life Don't know

Optional Benefits:
Return all premiums if you never claim:
Maintain daily benefit with cost of living:
Future Purchase Option:

Birth date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
vital stats:
Gender Male Female Height <4'10'' 4'10'' 4'11'' 5'0'' 5'1'' 5'2'' 5'3'' 5'4'' 5'5'' 5'6'' 5'7'' 5'8'' 5'9'' 5'10'' 5'11'' 6'0'' 6'1'' 6'2'' 6'3'' 6'4'' 6'5'' 6'6'' 6'7'' 6'8'' >6'8'' lbs. Tobacco Use None, Ever None in 5 years None in 3 years None in 1 year Pipes / Cigars Cigarettes Patch / gum

Tell us About Yourself:

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me A Long Term Care Insurance Quote NOW!

Daniel La Tour is our Licensed Life Insurance Agent in BC, AB, ON & QC.
For help and advice, contact Daniel La Tour.