long term care request for quote

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Welcome to a New School Year!

Take Advantage of the Benefits Offered by Citizens Insurance Company of America

LONG TERM CARE REQUEST FOR QUOTE

Special group rates are available to MEA and MEA-Retired members, member's parents, grandparents and member's children through MEA Financial Services for long-term care insurance.

For an information packet on the long term care products available please contact us at 1-800-292-1950 or complete our "Send Me Information" email form. You may request a long-term care insurance quote using one of the options below or by calling the above phone number.

If you are in excellent or good health and take no more than one medication*(see disclosure below) you may use our online form below to request a long-term care insurance quote,
or you may review and/or print off and mail our more comprehensive request for quote (includes a pre-qualification eligibility questionnaire).
You also have the option to order our long-term care insurance packet by completing our "Send Me Information" online order form.

We do not request detailed medical information online for a long-term care insurance quote. By requesting a quote online we will mail you a quote that assumes that you are eligible for coverage and in good to excellent health. If you are currently taking more than one medication (vitamins & allergy medications are not considered in the count) have a pre-existing medical condition that you believe may affect your rate or insurability, or if there are other factors that you feel may affect your eligibility or rate, you may call our office and speak to a representative to help determine a more accurate price quote.

We are licensed to quote and/or write long-term care insurance for Michigan residents only.

Not sure that you are eligible for long-term care insurance coverage? Access our pre-qualification eligibility questionnaire.

*DISCLOSURE: More than one medication does not mean than you would not qualify for our best rates (vitamins & allergy medications are not included in the number of medications)...it is just a guideline for online request for quotes. A more accurate quote can be determined by your using our mail in request for quote or by your calling our office. If you call our office for a quote, please have the names and dosages of all medications handy. Final eligibility is always determined by the companies underwriter after an application and down-payment has been made for coverage.

The following information is required to provide a quote for long-term care insurance. You may request an alternate quote using the Additional Comments area. We automatically send you some alternative pricing via option pages included with your quote. - MICHIGAN ONLY ! -

Email Address *

First and Last Name *

P.O. Box /Street Address *

City *

State *

Zip Code *

Daytime Phone(optional)

Member? *

Not a Member MEA MEA-Retired

School District

Your Date of Birth

Marital Status

Married Single

Your Health

Excellent Good

Height & Weight

Tobacco Use in the Past Year?

Yes No

Only complete this section when a quote is desired for your spouse.

Spouse's Name

Spouse Date of Birth

MM/DD/YYYY

Spouse's Health

N/A Excellent Good

Height & Weight

Tobacco Use in the Past Year?

N/A Yes Used Not Used

Make your selectons from the following. Not all options are available with the unlimited benefit or when a 180 or 365 day elimination period is chosen. We will base your request on the closest available option.

Benefit Period

2 years 3 years 4 years 5 years 6 years 10 years

Daily Benefit ($50 to $500 per day in $10 increments)

Or choose a Monthly Benefit ($1500 to $15000 per month)

Elimination Period

30 days 60 days 90 days 180 days 365 days

Inflation Protection

5% Compounding Consumer Price Index (CPI)-compound Consumer Price Index (CPI)-compound to Age 75 Guaranteed Purchase Option-

Payment Duration

Lifetime 20 Pay Paid up at Age 75

Included in all quotes: Alternate Care, Assisted Living, Adult Day Care, Hospice. Please select additional coverage you would like included below:

Surviviorship & Waiver of Premium Benefit

Yes Survivorship & Waiver No Survivorship & Waiver

Shared Care

Yes No

Waiver of Home Care Elimination Period

Yes No

Nonforfeiture of Benefit

Yes No

Additional Cash Benefit

Yes No

* Required

Please check to be certain that you have reviewed and completed all fields prior to submitting your request. You may use your back arrow for your browser to return to the original request form if your information fails to submit to check it for possible omissions. Call 1-800-292-1950, ext. 2278 if you wish to submit your information by phone.

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