Steps to get a free quote or application.

To request a free quote:
Step 1 — Complete and submit the form below.

Step 2 — We will Email you a premium chart based on your age and your state of residence.

To request an application:
Step 3 — Check the Application box below, provide email or mailing address where you want forms sent.

Step 4 — We can send the application by email or mail. Return the completed forms to start. It's best to apply a month before a birthday or a change of health.

Step 5 — If approved you have 30 days to accept, change, or decline the coverage.

This form is to receive information and is not an insurance application. You do not have to be a member. Name: Birth Date Weight: Lbs. Height: Ft. In. Spouse or Other Name*: Birth Date Weight: Lbs. Height: Ft. In. State of residence: (required -premiums and applications are state specific) Phone: Best days to contact you: M-F Sat Sun Best times to contact you: AM — PM Does either applicant take medications or have health problems? Self Spouse/Other If yes to above describe: (Not everyone is insurable but do not assume that you are not.) Send me an application : (email or mail below) Yes No E-mail to send info: (required) I currently have a LTC policy: Yes No Any comments: When do you plan to insure? select one ASAP this month 1-3 months 3-6 months more than 6 months How did you find our website? select one ARP website or article Radio or TV Newspaper or magazine Google Ad Web Search Relative, friend, co-worker Link on a website NOTES: * Quotes are valid for 14 days unless you have a birthday, a change of health. * Second applicants can be spouses, siblings, friends, etc. of same generation that share living expenses to qualify for multi-life discount. State laws require a signature for a medical records review. Underwriting application forms can be emailed or mailed but must be signed and returned. There is no obligation to see if you qualify. Call toll free 1-888-582-2464 or email if you have any questions.

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