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Please fill out the form below to submit information to EzLtcNY to help you compile an accurate quote.

Request Form

First Name: *

Last Name: *

Spouse First Name:

Street: *

City: *

State: *

Zip: *

Home Phone: *

Work Phone:

Cell Phone:

Email: *

Gender: *

Male Female

You

Your Height: *

Your Weight: *

Do you smoke?

List medications you take along with their daily quantity:
List all medical issues you've had in the last 10 years:

Do you currently have a long term care insurance policy:

Do you have any self-employment income:

Do you own a Health Savings Account (HSA):

Do you itemize on your federal tax return:

Do you own your own business:

Are you (or your spouse/partner) an actively employed (or retired) public safety worker. (i.e. police officer, firefighter, paramedic):

Your Spouse

Their Height: *

Their Weight: *

Do they smoke?

List medications they take along with their daily quantity:
List all medical issues they've had in the last 10 years:

Do they currently have a long term care insurance policy:

Do they have any self-employment income:

Do they own a Health Savings Account (HSA):

Do they itemize on your federal tax return:

Do they own their own business:

Are they (or you) an actively employed (or retired) public safety worker. (i.e. police officer, firefighter, paramedic):

Do you want to stay in your home for as long as possible?

Yes No

Current State of Residence: *

Future State of Residence:

All These Assets Are At Risk Please List Them:

Amount of Social Security:

Amount of Pensions:

Amount of Tax Qualified Plans (i.e. IRAs, 401ks, 403bs etc.):

Total Cash Value of Life Insurance:

Primary Residence (with land) Value:

All other property value:

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Request Form

You

Your Spouse

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