NY Area Long Term Care Insurance Quote

**Information received from this NY, CT, or NJ Long Term Care Insurance quote

request form sent to Direct Access Group Benefits will be for our use only

and will not be sold, given to or distributed to any other parties. A quote will be based

on the long term care insurance policy information provided and does not guarantee

acceptance of the risk by us. The precise coverage afforded is subject to meeting

underwriting guidelines, and the terms, conditions and exclusions of the policy as

issued. By submitting this request you acknowledge that this is neither an offer to

insure nor a guarantee of insurance. Completion of this form does not entitle you

to a Long Term Care Insurance Policy. We are licensed in New York, Connecticut, and

New Jersey, and will not provide long term care insurance quotes for other states.

We offer affordable long term care insurance policy premiums in the following New York
counties and cities: Westchester County, Putnam County, Orange County, Rockland County,
Port Chester, Harrison, Mamaroneck, Larchmont, New Rochelle, Yonkers, White Plains, Rye
Brook, Scarsdale, Rye, Ardsley, Hartsdale, Bronxville, Mt. Vernon, Mount Vernon, Irvington,
Valhalla, Elmsford, Dobbs Ferry, Hastings on Hudson, Greenburgh, Tarrytown, Sleepy
Hollow, Hawthorne, Scarborough, Thornwood, Briarcliff Manor, Ossining, Harmon,
Montrose, Crugers, Buchanan, Peekskill, Millwood, Pleasantville Armonk, Chappaqua, North
Castle, Mt. Kisco, Bedford, Pound Ridge, Bedford Hills, Cross River, South Salem, Yorktown
Heights, Goldens Bridge, Amawalk, Yorktown, Katonah, Salem Center, Somers, North Salem,
Croton Falls, Jefferson Valley, Shrub Oak, Palisades, Sparkill, Tappan, Orangeburg, Pearl
River, West Nyack, New City, Nanuet, Chestnut Ridge, Montebello, Suffern, Monsey, Spring
Valley, Congers, Nyack, Rockland Lake, Wesley Hills, New Hempstead, Pomona, Sloatsburg,
Ramapo, Hilburn, Willow Grove, Mt. Ivy, Thiells, Tomkins Cove, Ladentown, Haverstraw,
Stony Point, Tomkins Cove, West Haverstraw, Bear Mountain, Jones Point, Newburgh,
Middletown, and Poughkeepsie, NY.

Full Name:
Home Address:
City:     State:     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have long term care insurance?
Current Premium:$ per month

Coverage requested for?
Daily Benefit Amount: $
Benefit Period:
Elimination Period:
Payment Mode:

Do you own or rent your primary residence?
What amount do your current assets total?

Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender: Spouse Height: ft. inches     Spouse Weight:
Does your Spouse smoke?
Is Spouse married to Applicant?

Is Spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Additional Comments or Requests

Click on the "Submit Quote Information" button below to send
your NY, CT, or NJ Long Term Care Insurance quote request.**

We also offer affordable long term care insurance policy premiums in the following Connecticut counties and
cities: Fairfield County, Stamford, Norwalk, Greenwich, Darien, Riverside, Belltown, Springdale, Round Hill, Old
Greenwich, East Norwalk, New Canaan, Glenville, Byram, Cos Cob, Mianus, North Stamford, Glenbrook, Wilton,
Weston, Long Ridge, Noroton, West Norwalk, Westport, High Ridge, Southport, North Wilton, Winnipauk,
Cannondale, Turn of River, South Wilton, Lyons Plains, Georgetown, Ridgefield, Branchville, Redding,
Topstone, Ridgebury, Redding Ridge, Branchville, Dodgingtown, West Redding, Titicus, Hattertown, Bethel,
Danbury, New Fairfield, Newtown, Hawleyville, Botsford, Monroe, Bridgeport, Stepney, Shelton, Huntington,
Upper Stepney, Long Hill, Trumbull, Stratford, Easton, Fairfield, Greenfield Hill, Stratfield, Nichols, Oronoque,
Rivercliff, Devon, Lordship, and East Bridgeport, and New Haven, CT.