Keller Insurance Agency
Barry Keller - Owner
P.O. Box 715
Warren, Pa 16365
(814) 726-0305
Serving Clients Since 1926


 
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Long-Term Care Insurance
Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible.  Once submitted the information will be e-mailed to our office(s) and we will expedite your request.  This information will be kept confidential and will be used for quote purposes only.  We look forward to serving you.
 

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information

* Name:
Address:
City:  State:   Zip:
Phone: * Work:
* Home: 
   
 Fax: 
* Email Address:

Quote Information

Date of Birth: //
Gender: Male   Female
Smoker?: Yes   No
Height & Weight: (ex: 5' 8")
 (ex: 150 lbs)
Daily Benefit ($50 - $500):
Waiting Period (0 - 365):
Benefit Period: Lifetime
3 years or more
12 to 35 months
Include Home Health Care Coverage?: No   Yes
Include Compound Inflation Rider Coverage?: No   Yes
Please describe any and all health conditions that resulted in hospitalization and/or surgery in the past 10 years:

Spouse/Companion Information

Relationship?: Spouse   Companion
Name:
Gender: Male   Female
Date of Birth: //

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.


Please click on the "Submit Request" button to send us your quote request.
Upon successful completion, you will be returned to our Home page.