The Ezell Group Insurance Agency

Group Long Term Care Insurance Quote

Group Name:

Telephone:

Group Contact:

Fax:

Group Address:

City, State & Zip:

E-Mail Address:

# of employess to be insured:

Type of Business:

How long in business:

Do you currently offer long-term care insurance to employees?

Yes No

Want long-term care insurance coverage for:

Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group LTC Insurance Information

Carrier (Company) Name (not agency):

Policy Expiration Date:

Premium Amt:

Years Insured:

Please give a brief description of your current Group LTC plan:

Coverage Options

Type of Coverage:

New Coverage
Additional Coverage
Replacement

Waiting Period:

Daily Benefit Amount:

Benefit Period:

Inflation Protection:

Do you want your policy to include home-health care coverage?

Yes No

Employee Information
(If More Than 10 Employees, place call us to receive a large group census form or use the additional comments box below to add remaining employees.)
Please list all employees you wish to cover:

Employee #	Employee Name	Birth Date (mm/dd/yy)	Gender	Salary	Select Coverage
# 1
# 2
# 3
# 4
# 5
# 6
# 7
# 8
# 9
# 10

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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