Please complete all sections, then select Submit at the bottom of the final page.

 
 11% of survey complete.
Complete this health questionnaire to be prequalified and receive quotes.   
 
Estimated 2 to 5 minutes to complete.  Simply close your browser if you want to stop and not submit your answers.
 
After we review your answers, we will email you a personalized quote and explain the application process.
  • This is NOT an application for insurance.  This information is used to determine your eligibility to apply for a policy.  If you qualify, we will contact you and when you are ready, assist you with an electronic application. 
  • Health information is ONLY used to assess your eligibility for insurance.
  • Your contact information is ONLY used to respond to your inquiry. 
  • We will not market other products and services to you and your information is not sold or provided to others. 
  • One questionnaire per person.  You may complete for someone else if familiar with their health history.   
  • Questions or prefer to provide this information by phone? (855) 204-1214
 
This Questionnaire is HIPAA compliant.
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* 1. What coverage amount was of greatest interest to you?

We will email you quotes on all three as well as any amount you specify. 

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* 2. State of residence (Product unavailable in CA & NY)

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* 3. What is your Date of Birth (MM/DD/YYYY)?    Product available for ages 18-85

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* 4. What is your height?  (feet and inches)

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* 5. What is your weight?

Review height/weight chart for eligibility.  

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* 6. Have you used any tobacco products in the last 12 months?

LTCI Partners was selected by the HCG Secure to help consumers with this important planning.

LTCI Partners, LLC, (LTCI Partners) acts as an agent for select insurance companies to provide insurance under this program. Invitations for application for insurance are made through LTCI Partners. LTCI Partners or its licensed representatives are currently licensed in all 50 states and the District of Columbia. California license number 0D51716. Other license numbers are available upon request. LTCI Partners receives commissions from insurance carriers, which include compensation based on total quantity and quality of insurance coverage.

The insurance policy describes coverages under the policy, exclusions and limitations, what you must do to keep your policy in force, and what would cause your policy to be discontinued. Please contact your licensed agent for more information, costs, and complete details on coverage. Availability of policies, features, and benefits may vary by state.

An insurance agent may contact you. Premiums vary by issue age and health and for some plans may be increased in the future. The insurance is underwritten by the insurance company we help you select. Your application approval is not guaranteed.

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