All quotes are offered by Eck Agency, Inc a Kansas licensed agency.  They are quotes only, not contracts and are subject to underwriting by the respective companies.  If you live outside the state of Kansas, you will not receive a reply.  

You will be contacted by an agent with information and tentative rates 

Long Term Care Insurance Quote Request

Primary Insured
Name
Address
City/State   
Daily Benefit
Other benefits
Inflation Rider Home Health Care
Age
Gender
Tobacco Use
Do you have a Spouse?
Spouse Age
Gender
Tobacco Use
Do you use a walker or cane of any kind?

Spouse? 
Are you currently on Oxygen?

Spouse?

Are you currently taking prescription medications?

Spouse? 
Have you been hospitalized in the last 5 years?

Spouse?
You or spouse ever been treated for any of the following?
Heart Disease Diabetes
Cancer Rheumatoid Arthritis
Stroke Immune Disorder

Contact Information
Home Phone
Work Phone
Cell Phone
Fax
Best Place to Contact Home      Work    Cell
Best Time to Contact Morning   Afternoon   Evening
Comments

 

All quotes and information offered by Eck Agency, Inc, a licensed Kansas agency.  Call 1-800-444-4911

Copyright © 2003 Eck Agency, Inc. All rights reserved  
Revised: December 12, 2006