Guardian Long Term Care Insurance Quote Request Form

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Long Term Care Insurance Quote Request

In order to obtain a quote please fill out the following form and click "SUBMIT" below. We will automatically receive your information and begin working on your quote immediately. You have the option to request the quote via fax, or through the mail. We sincerely appreciate the opportunity to write more business with you. If you would like to call us to discuss a quote, our number is 240-683-9700 in Rockville.

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Your Information
Your Name:
Your Company:
Your Address:
Your City:
Your State:
Your Zip:
Your Phone Number:
Your Fax Number:
Your E-mail Address:

Primary Insured		Spouse/Partner
	Insured's Name
	Date of Birth
	State
	Height
	Weight
Male Female	Gender	Male Female
	Last Tobacco Use
	Surgeries past 5 yrs

Daily Benefit:
Benefit Duration:
Elimination Period:
Inflation Protection:
Benefit Type:

Has the client been treated for any of the following conditions in the last 5 years?
Primary Insured	(check all that apply)	Spouse / Partner
	High Blood Pressure
	Heart Attack, Angina, Angioplasty or Atria Fibrillation
	Stroke or TIA
	Arthritis
	Type I Diabetes (insulin)
	Type II Diabetes (oral meds)
	Neuropathy or Retinopathy
	Osteoporosis (list T-Score below)
	Compression Fractures
	PSA (prostate test) for men (list score below)
	Cancer (list type and treatment below)
	Fibromyalgia
	Anxiety/Depression
	Lupus (list type below)

Please list other health issues or any relevant details on above conditions Also, please list any prescription Meds & Dosages, with Reason prescribed
Primary Insured	Spouse/Partner

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Financial Balance Group LLC is a general agency of The Guardian Life Insurance Company of America, NY, NY. Guardian Disability Insurance Brokerage is the brokerage arm of Financial Balance Group LLC. Disability insurance agent information provided on this web site is for broker use only.
Steven L. Crawford (General Agent). (c) Guardian Disability Insurance Brokerage 2000.
See "Disclaimer" link to the right for policy series and details.

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