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Advisor quote request

Long-Term Care Quote Request

Traditional, partnership, hybrid life/LTC, life with LTC riders and annuity-based LTC. Quote an individual or a couple.

Two ways to send it: fill out the form below online, or download the PDF, complete it and upload it here or email it to tjfuller@srsinc.com.

↓ LTC intake form (PDF)↓ LTC quote request (PDF)Submit online ↓

Submit online

Long-Term Care Quote Request

Agent information

Agent name(Required)

First Last

Agent email(Required)

Agent phone(Required)

Agency / contact person

Date of appointment

MM slash DD slash YYYY

Signing state

Client information

Quote for(Required)

Single (one person)

Couple (husband and wife / partners)

Client name(Required)

First Last

Client date of birth(Required)

MM slash DD slash YYYY

Client sex(Required)

Male

Female

Marital status

Married

Partnered

Single

Widowed

City

State(Required)

Zip code

Spouse / partner name(Required)

First Last

Spouse / partner date of birth(Required)

MM slash DD slash YYYY

Spouse / partner sex(Required)

Male

Female

Coverage interest

Products to compare

Traditional LTC insurance

Partnership-qualified LTC

Hybrid life / LTC (asset-based)

Life insurance with LTC or chronic illness rider

Annuity with LTC benefits

Not sure, recommend options

Desired benefit (monthly or daily amount, benefit period, inflation option)

Annual premium budget

Monthly premium budget

Open to repositioning assets (single premium or limited pay)?

Yes

No

Maybe

Health: client

Client height

Client weight

Client: check any that apply

LTC insurance ever denied or rated up

Receiving disability benefits

Tobacco use in the last 5 years

Hospitalized in the last 5 years

Narcotic pain medication or medical marijuana

Treated for diabetes (give insulin use and A1C in details)

Parent diagnosed with dementia (give age in details)

Cancer treatment in the last 5 years

Heart disease treatment in the last 5 years

Sleep apnea treatment in the last 5 years

Rheumatoid arthritis or autoimmune disorder in the last 5 years

Vertigo

Musculoskeletal disorder

Medication changes in the last 6 months

Uses a wheelchair, walker, quad cane or hospital bed, or has a handicap sticker

Cognitive impairment or needs help with activities of daily living

Client details for any items checked (diagnosis, date, treatment plan)

Client medications (name, dosage, frequency, reason prescribed)

Client: date of last complete physical with CBC testing

Health: spouse / partner

Spouse height

Spouse weight

Spouse: check any that apply

LTC insurance ever denied or rated up

Receiving disability benefits

Tobacco use in the last 5 years

Hospitalized in the last 5 years

Narcotic pain medication or medical marijuana

Treated for diabetes (give insulin use and A1C in details)

Parent diagnosed with dementia (give age in details)

Cancer treatment in the last 5 years

Heart disease treatment in the last 5 years

Sleep apnea treatment in the last 5 years

Rheumatoid arthritis or autoimmune disorder in the last 5 years

Vertigo

Musculoskeletal disorder

Medication changes in the last 6 months

Uses a wheelchair, walker, quad cane or hospital bed, or has a handicap sticker

Cognitive impairment or needs help with activities of daily living

Spouse details for any items checked (diagnosis, date, treatment plan)

Spouse medications (name, dosage, frequency, reason prescribed)

Spouse: date of last complete physical with CBC testing

Financial information

Monthly gross amounts.

Client monthly income: employment

Client monthly income: Social Security

Client monthly income: pension(s)

Client monthly income: other

Spouse monthly income: employment

Spouse monthly income: Social Security

Spouse monthly income: pension(s)

Spouse monthly income: other

Assets

Assets that are commonly repositioned to fund LTC coverage.

Retirement accounts

Roth retirement accounts

Stocks and bonds

Checking and savings

CDs or money market

Life insurance cash value

HSA account

Home value (if owned)

Non-qualified annuities (value, gain, owner for each)

Upload or notes

Upload a completed LTC intake form or supporting documents (optional)

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 3.

PDF, Word or image files. Up to 3 files, 10 MB each.

Additional notes

What happens next

We review the request, shop the carriers that fit, and respond within 1 business day. You will get an email confirmation as soon as you submit.

See product options, costs and sales tools on our long-term care page.

Other quote requests

Life insurance
Disability income
Long-term care
Annuities

Questions? Call 303-309-3471.

Search for:

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CPS Special Risk Services
6901 S. Pierce St. Suite 300
Littleton, CO 80128

Phone: 303-309-3471
Toll-free: 1-888-444-7475
Fax: 303-309-3470
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