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Long Term Care

Long Term Care is needed by any person who requires help with the activities of daily living (ADLs) or who suffer from cognitive impairments.

This type of coverage is designed to help pay some or all long term care costs, reducing the risk that the policyholder would need to deplete his or her assets to pay for long term care. It can help a person avoid relying on family or friends for assistance, and can reduce or eliminate the need to rely on Medicaid.

Please complete the information below and submit it to us be either email or fax and we will reply promptly to your request. You can not submit an inquiry without supplying the information highlighted with an asterisk (*).

Please answer the following questions:

Do you currently have another Long Term Care policy or certificate in force: Yes No If so, name of carrier: Do you currently have any health insurance policies that provide some duplicate benefits: Yes No Name:* Phone #:* Date of Birth:* (MM/DD/YYYY) Sex:* Male Female Your Zip Code:* (5 digits) State: Will Your Spouse be Insured:* Yes No Spouse's Date of Birth:* (MM/DD/YYYY)

Submit this information:

Or print out form and fax to: (847) 866-7414

DISCLAIMER: FINANCIAL AND MEDICAL UNDERWRITING DECISIONS ARE THE DIRECT RESPONSIBILITY OF THE INSURANCE CARRIER. BDM Combined, Inc. ASSUMES NO LIABILITY FOR SUCH UNDERWRITING DECISIONS.

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