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P I A M
860 Winter Street
Waltham, MA 02451-1414
toll free 800-522-7426
tel 781-434-7525
fax 781-434-6929
         

 
 

 Long Term Care
General Information
Name:
Address:
City:
State:
Zip:
Date of Birth:
Affiliation:
Spouse Name:
Spouse Date of Birth:
Home Phone:
Best Time to Call:
E-Mail:
Fax:
Request for Customized Proposal
Have you smoked cigarettes in the last 3 years? Yes No
Do you work more than 30 hrs / week outside your home? Yes No
Consider these costs: nursing home care at $220 per day; assisted living residences at $140 per day; and home health care at $120 per day. You can plan to pay all or a portion of this expense with long term care insurance. what would you like your plan quote based on?
Insurance Pays
  
100% of the cost: $220 per day
80% of the cost: $180 per day
60% of the cost: $140 per day
Other:
The average length of stay in a skilled nursing facility in most areas of Massachusetts is 2.7 years. This does not count the number of days a person spends receiving home health care or staying in an assisted living residence. Most people purchasing a long term care plan choose insurance policies that will pay benefits for an average of four years of care. Choose one of the following benefit periods for your customized plan:
Average benefit period:
Less than average:
Greater than average:
Are you reviewing another long term care carrier? If so would you like a direct comparison:
Carrier:
Benefits:
Premium:
Comments:
Submit:
 
Disclaimer: Our online application forms are to provide current and prospective clients an indication of premium only. No coverage can be bound by this process. Hard copy, original signature, long form applications must first be obtained. Only after an insurance company has underwritten and provided written terms from this office can coverage be ordered.
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