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Long Term Care Quote Request

*First Name:

*Last Name:

* = Required

*E-mail Address:

*Address:

*City:

*State:

*ZIP Code:

*Phone Number:

*Date of Birth:

*Gender:

Male Female

*Married:

Yes No

*Is spouse applying for coverage?

Yes No

*State of Residence:

*Tobacco user?

Yes No

Known health condition (include onset dates, treatment, and medications):

Please provide the following spouse information if applying for spousal coverage:

Full Name:

Date of Birth:

Gender:

Male Female

State of Residence:

Tobacco user?

Yes No

Known health condition (include onset dates, treatment, and medications):

Daily benefit amount? ($100-$250):

Elimination period:

0 30 60 90

Benefit period:

2 yrs. 3 yrs. 4 yrs. 5 yrs. Lifetime

Home health care %:

0 50 75 100

Non - Forfeiture rider:

Yes

Automatic benefit increase rider (5%):

Simple Compound

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Thank you for completing the Long Term Care Request form. Please click on the 'Submit to AAA' button below to submit the information to the AAA Ohio Motorists Insurance Agency.