Long Term Care Insurance Quote NH

We are your local southeastern New Hampshire, southern Maine
insurance agency, offering affordable long term care insurance policy
premiums in the following cities and counties: Somersworth, Durham,
Portsmouth, Dover, Rochester, Rollinsford, Barrington, Madbury, Lee,
Strafford, Farmington, Milton, Barnstead, Nottingham, Northwood,
Raymond, Newmarket, Newfields, Stratham, Rye, Hampton, Epping,
Exeter, Salem, Danville, Deerfield, West Rye, Derry, Chichester, South
Barnstead, Gilmanton, New Durham, Wolfeboro, Alton, Laconia, Berlin,
Lebanon, East Candia, North Hampton, Hanover, Littleton, Plymouth,
Claremont, Newport, Keene, Hampton, Rye Beach, Strafford County,
Rockingham County, Hillsborough County, Merrimack County, and
Belknap County, NH. We also offer long term care insurance policy
services throughout the state of New Hampshire, including the
Manchester, Nashua, and Concord area. Our service area in southern
Maine includes the following cities and counties: South Lebanon,
Kittery, Eliot, Berwick, Sanford, Blaisdell Corners, Springvale, Emery
Mills, Wells Beach, York Beach, Kittery Point, Kennebunk, Saco,
Biddeford, Alfred, Portland, Scarborough, Westbrook, Waterboro,
Shapleigh, Newfield, Buxton, Goodwins Mills, South Sanford, Cape
Elizabeth, South Portland, York County, and Cumberland County, ME.

Full Name:
Mailing Address:
City:
State: (New Hampshire or Maine)
Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?
Do you currently have long term care insurance?
Current Premium:$ per month

New Hampshire Long Term Care Insurance Coverage Information:

Coverage requested for?
Daily Benefit Amount: $
Benefit Period:
Elimination Period:
Payment Mode:

Asset Information:
Do you own or rent your primary residence?
What amount do your current assets total?

Medical Information:
Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please
provide the necessary information below:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender: Spouse Height: ft.
Spouse Weight:
Does your Spouse smoke?
Is Spouse married to Applicant?

Is Spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please
provide the necessary information below:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Additional Comments or Requests

Click on the "Submit Quote Information" button below to send
your New Hampshire Long Term Care Insurance quote request.**

**Information received from this New Hampshire Long Term Care Insurance quote request form sent to Gorman Insurance and Risk Management Services, will be for our use only and will not be sold, given to or distributed to any other parties. A quote will be based on the long term care insurance policy information provided and does not guarantee acceptance of the risk by us. The precise coverage afforded is subject to meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By submitting this request you acknowledge that this is neither an offer to insure nor a guarantee of insurance. Completion of this form does not entitle you to a New Hampshire Long Term Care Insurance Policy. We are licensed in New Hampshire, Maine and Massachusetts, and will not provide quotes for other states.