Connecticut Long Term Care Insurance Quote

We offer affordable long term care insurance premiums from quality
insurance companies to residents in the following Connecticut counties and
cities: Fairfield County, New Haven County, Litchfield County, Middlesex
County, New London County, Hartford County, Tolland County, Windham
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, New Haven, Hartford,
Torrington, Waterbury, Meriden, New Britain, New London, Norwich,
Manchester, East Hartford, Suffield, Granby, West Haven, West Hartford,
Branford, East Haven, Hamden, Woodbridge, Orange, North Haven, Groton,
Rocky Hill, Newington, Wethersfield, Glastonbury, Bloomfield, Blue Hills,
South Windsor, Naugatuck, New Hartford, Chesire, East Lyme, Old Mystic,
Wallingford, Southington, Middletown, Bristol, Laurel Beach, Litchfield,
Pleasure Beach, Mystic, North Westchester, Double Beach, Willimantic,
Storrs, Canaan, East Windsor, Vernon, South Canaan, Putnam, Guilford,
Windham, South Britain, Willington, Windsor, East Hampton, Brooklyn, and
Westchester, CT.

Information received from this Connecticut long term care insurance quote form sent to Stamford
Insurance Group 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 long term care insurance 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 Connecticut long term care
insurance. We are licensed in Connecticut, New York, New Jersey, Massachusetts, and Rhode
Island. We will not provide quotes for other states.

Full Name:
Home Address:
City:     State:     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have long term care insurance?
Current Premium:$ per month

Coverage requested for?
Daily Benefit Amount: $
Benefit Period:
Elimination Period:
Payment Mode:

Do you own or rent your primary residence?
What amount do your current assets total?

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

If you answered "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender: Spouse Height: ft. inches     Spouse Weight:
Does your Spouse smoke?
Is Spouse married to Applicant?

Is Spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Additional Information or Comments

Click on the "Submit Quote Information" button below to send
your Connecticut Long Term Care Insurance quote request.