Life Insurance

Newbrook Insurance Agency	14 Roosevelt Avenue Port Jefferson Sta., NY 11776 (631) 473-7059
"Providing Financial Protection For Our Clients Since 1969"	info@newbrookins.com

Long Term Care

If you would like to receive a long term care quote, please fill out the following form. Our Certified Financial Planners are available to discuss any questions that you may have. Please call at 800-833-5610 and dial extension 109 or 107.

Name
Date of Birth
Smoker?	Yes No
Is Spouse Applying for Coverage?	Yes No
Spouse Name
Spouse Date of Birth
Is spouse a smoker?	Yes No
Marital Status (Answer even if only 1 spouse is applying)
Coverage Information
Nursing Home Daily Benefit Amount
Home Health Care Benefit	50% 80% 100%
Elimination Period (days)	0 20/30 60 90/100
Benefit Period (years)
Inflation Option	None 5% Simple 5% Compound
Underwriting Information
If applicant is NOT 'normal' weight, please specify	Spouse 1: Height Weight Spouse 2: Height Weight
Please Describe Underwriting Concerns
Other Comments or Concerns
Contact Information
How would you like to be contacted?	Mail Email
Phone (optional)
Email Address
Street Address
City, State, Zip