Georgia life insurance, health insurance, disability and long term care insurnace from georgia-life-health-disability.com
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Complete our simple One-Screen Online Quote Forms (takes only 2 minutes!) and get a custom quote from Georgia's leading insurance companies. Choose the insurance plan that is best for you and your family, or select the service you need below:

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  • Long Term Care Quote
  • Group Long Term Care

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    •   Request a FAST Online Quotation Below!
     

     
    On-Line Group Long Term Care
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!

    Your Personal Data

    Your Name:
    Street Address:
    City:
    State: (Must be Georgia)
    Zip Code:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    Phone:
    Fax (optional):
     
    Group Long Term Care Ins. Currently?
    (If yes, list carrier, and # of years
    continuous. If none, type N/C)
     

    UNDERWRITING INFORMATION
     
    List employees' names, and other census data:
    (If More Than 10 Employees, place call us to
    receive a large group census form.)

    Employee #1 Name:B-Date: M/F:
    Employee #2 Name:B-Date: M/F:
    Employee #3 Name:B-Date: M/F:
    Employee #4 Name:B-Date: M/F:
    Employee #5 Name:B-Date: M/F:
    Employee #6 Name:B-Date: M/F:
    Employee #7 Name:B-Date: M/F:
    Employee #8 Name:B-Date: M/F:
    Employee #9 Name:B-Date: M/F:
    Employee #10 Name:B-Date: M/F:

    COVERAGE INFORMATION
     
    What Daily Benefit Amount Needed? (In Dollars $)
     
    What Waiting Period Do You Want?
    (30 days, 60 days, 90 days, etc.):
     
    Any special coverages needed?
    (Such as Home Health Care Cov., Compound Inflation Rider, etc.)
     
    Tell Us What You Want MOST in this long term care plan, or list any other Remarks here:

    Send my quotation via: E-Mail Fax
    Regular Mail
    Call me by Phone!

    Thank you for filling out this form COMPLETELY!

    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

    Yes, I Agree. Please Send Me My
    Long Term Care Quote NOW!

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    Southern Financial Consultants | 2994 Shenendoah Valley Road | Atlanta, GA 30345 | E-Mail: brucewinston@msn.com
    Phone: 404-822-3437 | Fax: 678-623-0555 | GA Ins. Lic# 707716 | Our Privacy Notice | Map/Driving Directions

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