LTC Agent Quote Request - Pegasus Insurance Group

Pegasus LTC Agent Quote Request

Client Personal Information:

Please use the tab key to proceed to each answer field. Pressing the enter key will submit the form.

Client Health Information:

How many times a week do you exercise, work outside your home, go to social functions or volunteer?
Has client or spouse used a tobacco product in the last 5 years?
Client: Yes No
Spouse: Yes No
How would you classify your health?
Client:
Spouse:
Has either client or spouse been hospitalized in the past 5 years? If so, please explain.
Client: Yes No Reason:
Spouse: Yes No Reason:
Has client or spouse been medically diagnosed with any of the following: Alzheimer's, Chronic memory loss, MS, Parkinson's or Multiple strokes?
Client: Yes No Description:
Spouse: Yes No Description:
Do either client or spouse use a wheelchair, walker, oxygen or kidney dialysis?
Client: Yes No Description:
Spouse: Yes No Description:

Does client or spouse currently own a Long Term Care Insurance Policy, if so with which company?

Client: Yes No
Company

Spouse: Yes No
Company

Other Companies client may be considering for coverage:

Additional comments:

(with this information we can provide you a FREE Benefit Analysis!)

Agent Information:

When would be the best time to contact you?
Morning Afternoon Early Evening

Agent Name: (required field)

Phone Number: (required field)

E-Mail: (required field)

Please click the "Submit" button when you have completed this form.
We will process your quote request promptly!