Get a Quote for Long Term Care Next Previous Reason to buy long Term Care Works well with Estate Planning Protect Family Inheritance/Assets Protect your Quality of Life Protect $1 for $1 on a Tax Qualified Plan Questions to ask about long term care How much do I need How long do I need it for How do I set the policy up What are the tax benefits Get in Touch With A-1 Insurance Group, Inc. Name* First Last Address* Apt number/unit City State Zip Code County*Phone Number*Email* Height*4ft5ft6ft7ft8ft9ft10ftInches123456789101112WeightDate of Birth* MM slash DD slash YYYY Use Tobacco*YesNoHealth conditionsDo you take a medication?NoYesMedication Name*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 1*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 2*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 3*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 4*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 5*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 6*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 7*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 8*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 9*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 10*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 11*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 12*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 13*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 14*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 15*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 16*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 17*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 18*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 19*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 20*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 21*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 22*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 23*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 24*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 25*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 26*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 27*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 28*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 29*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 30*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 31*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 32*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 33*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 34*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 35*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 36*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 37*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 38*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 39*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*Add another medication*NoYesMedication Name 40*Quantity*Per*DayWeeksMonthsThree MonthsType*PillsCannisterTubesBottlesVialsPatchesDosage Type*MGMCGUnits Per Day%SOLUTIONDosage Amount*This field is hidden when viewing the formHow long do you need the policy to last?*1 year2 years3 years4 years5 years6 years7 years8 years9 years10 yearslifetimeMonthly Benefits Requested*$1000$2000$3000$4000$5000$6000$7000$8000$9000$10000$11000$12000$13000$14000$15000Elimination Period*0 days30 days60 days90 days180 days365 daysInflation Protector*YesNoDoes it need to be partnership qualified?*YesNoNameThis field is for validation purposes and should be left unchanged.