NY Long Term Care Insurance Quote

**Information received from this NY, CT, or NJ Group 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 group long term care insurance plan 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 Group Long Term Care Insurance plan policy. We are licensed in New York,

Connecticut and New Jersey, and will not provide quotes for other states.

We offer affordable New York group long term care insurance plans for businesses 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.

Business Name:
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required)
Description of Operations or SIC code:

Current Insurance Company:
Policy Expiration Date:          (mm/dd/yyyy)

Do you currently offer long term care insurance to employees?
Want Long Term Care Insurance Coverage For:
How many employees to be insured:

Has any employee to be insured experienced serious health
problems during the last 18 months?
If "Yes", please explain below.

Additional Information or Comments

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

We also offer affordable group long term care insurance plans for businesses 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.