Applicant Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Daytime Phone:

Cell Phone:


Email:  (Required)


How Best To Contact You:
Select One Cell Phone Daytime Phone Email


Currently Insured:
Select One Yes No


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


Select One Yes No



Insurance Information

Date of Birth:

Gender:
Select One Female Male
Height:

Weight:


Do You Smoke:
Select One Yes No

Do you currently own Long:
Term Care Insurance:
Select One Yes No

If Yes, what is your monthly premium:
$



Choose Coverage Limits

Coverage For:
Select One Applicant Applicant & Spouse Others

Type of Coverage Needed:
Select One Accident Only Health Only Accident & Health

Daily Benefit Amount Desired:
Select Amount $100 $150 $200 $300 $400 $500

Benefit Period:
Select One 1 year 3 years 5 years lifetime

Elimination Period:
Select One None 90 days 190 days 1 year

Payment Mode:
Select One Annual Semi-Annual Quarterly Monthly



Asset Information

Own or rent your primary residence:
Select One Yes No

Your current assets total:
Select One $50,000 to $100,000 $100,000 to $200,000 $200,000 to $500,000 $500,000 to $1 million Over $1 million



Question or Message:




Click the "Submit Quote Request"
button below to send your New York
Long Term Care Insurance request
to Direct Access Group Benefits.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***

We are a Somers, NY insurance
agency offering New York long
term care insurance quotes in the
following towns, cities and counties
in the Westchester County, NY area:
Port Chester, Harrison, Mamaroneck,
Larchmont, New Rochelle, Yonkers,
White Plains, Rye Brook, Scarsdale,
Rye, Ardsley, Hartsdale, Bronxville,
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, Bronx,
New York City, Brewster, Poughkeepsie,
Putnam County, Orange County, and
Rockland County, New York.



Direct Access Group Benefits, Inc.
189 Route 100, PO Box 590
Somers, New York 10589
Westchester County, New York

Long Term Care Insurance Quote

Direct Access Group Benefits, Inc.
© 2004, All Rights Reserved