DBS Brokerage Services Inc

Employer/Employee MyWave Portal CommCenter

Phone: (609) 903-7661
E-mail: Info@DBSBrokerage.com

	Health Insurance

	Health Reimbursement Arrangements

	Health Savings Accounts

	Life Insurance

	Disability Insurance

	Long Term Care Insurance

	Dental Insurance

	Voluntary Workplace Benefits

	Flexible Spending Accounts

	Employee Assistance Programs

	Insurance Sites

Individual Long Term Care Quote Request

Please complete the following information if you would like to obtain a quote on Long-Term Care Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
	First
	Middle
What is your e-mail address?	e-mail
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Day
What is your telephone number?	Evening
What is your fax number?	Fax
What is your birth date?	Birth Date
What is your gender?	Gender	Male Female
What is your height?	Feet plus inches (example 5'8")
What is your weight?	Weight
Are you married?	Yes No	Spouse's Birth Date?
Fill in spouse if spouse is also applying
	Self	Spouse
Do you smoke?	Yes No	Yes No
Are you diabetic?	Yes No	Yes No
Are you insulin dependent?	Yes No	Yes No
Do you use a cane?	Yes No	Yes No
Do you use a walker?	Yes No	Yes No
Do you use a wheel chair?	Yes No	Yes No
Do you use any other equipment?	Yes No	Yes No
If you have required assistance with everyday activities in the past 2 years, please explain
In the past 5 years have you:
been confined to a hospital?	Yes No	Yes No
nursing home?	Yes No	Yes No
had home care?	Yes No	Yes No
had long-term care?	Yes No	Yes No
received rehabilitation?	Yes No	Yes No
Please describe your particular health problems
Prescribed medications
Do you currently own a long-term care policy?	Yes No	Yes No
Long-Term Care Quote Selections
Benefit period desired	(Average stay in a nursing facility is about 3 years)
Daily Benefit - nursing home coverage
Daily benefit - home & community care
How long can you afford to pay for a stay in a nursing home out of your savings without having to sell any of your assets such as your home, property, cars, investments, etc?	The average cost per month is $5,000 which could be more depending on area of country
Inflation protection/cost-of living adjustment	Most needed for younger applicants
Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or specify other:

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