One Company, Endless Solutions

The Metropolitan Agency provides Personalized Insurance and Risk Management Solutions in the
New York Tri-State Area.


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Group Long-Term Care Insurance Quote Request

Please take a moment to fill out the form below and one of our local insurance agents will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Legal Name of Business:
Contact Name: *
Middle name:
Date of Birth:
Gender:	Male Female
Marital Status :
Address:
City:
State:
Zip:
County:
Business Phone: *
Best Time To Call:	AM PM
E-mail Address: *

If living at current address less than two years, provide previous address
Street :
City:
State:
Zip:
County:

Business Information
Type of Business:
Number of Employees to be Insured:
Do you currently offer long-term care insurance to employees?	Yes No
Want long-term care insurance coverage for:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group LTC Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:	Premium Amt: $
Years Insured:
Please give a brief description of your current Group LTC plan:

Coverage Options
Type of Coverage:	New Coverage Additional Coverage Replacement
Waiting Period:
Daily Benefit Amount:
Benefit Period:
Inflation Protection:
Do you want your policy to include home-health care coverage?	Yes No

Additional Comments or Questions

	Enter Security Code:

Please click the "Submit Quote Request" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

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