GROUP LONG-TERM CARE INSURANCE QUOTE (Customized and personalized)
CONTACT
First Name: Last Name: Phone Number (Including Area Code):
Email Address: Title:
Company Name: Type of Business: Years in Business:
Is there a DBA? If so, please list:
Legal Structure of Business:
Number of full-time employees (EE): W-2 1099 Number of employees on COBRA:
Do you CURRENTLY have group LTCi coverage: CURRENT carrier name:
EMPLOYEE INFORMATION
LAST NAME FIRST NAME M / F DATE OF BIRTH SPOUSE STATE ANN. SALARY JOB TITLE
INSURANCE & ANNUITIES
RETIREMENT
EMPLOYEE BENEFIT PLANS
WEALTH PRESERVATION
BUSINESS PLANNING
REVERSE MORTGAGES
Mendonca Insurance Services
949.954.4445
Please use the area below for any notes and don't forget to click on the SUBMIT BUTTON
I was referred by:
Desired Effective Date:
Insurance
Annuities
Retirement Income
Tax Avoidance Strategies
Your INDEPENDENT Resource
949.954.4445
Would you like a quote on:
Are you CURRENTLY working with a broker:
If YES, would you consider replacing us as your Broker of Record
PLEASE COMPLETE THE INFORMATION BELOW FOR THOSE EMPLOYEES WHO ARE LIKELY TO PURCHASE LONG-TERM CARE INSURANCE.
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