GROUP LONG-TERM CARE INSURANCE QUOTE (Customized and personalized)
CONTACT    
First Name:                            Last Name:                                       Phone Number (Including Area Code):                             

Email Address:                                                                            Title:               

Company Name:                                                                           Type of Business:                        Years in Business:       

Is there a DBA? If so, please list:                                                                        

Legal Structure of Business:                                                                     

Number of full-time employees (EE): W-2               1099              Number of employees on COBRA:             

Do you CURRENTLY have group LTCi coverage:                   CURRENT carrier name:                                



                                                             
                                                                         
                                                                               
                                                                         
                                                                                           


                                       







EMPLOYEE INFORMATION
LAST NAME           FIRST NAME   M / F  DATE OF BIRTH  SPOUSE    STATE  ANN. SALARY         JOB TITLE

INSURANCE & ANNUITIES
RETIREMENT
EMPLOYEE BENEFIT PLANS
WEALTH PRESERVATION
BUSINESS PLANNING
REVERSE MORTGAGES
Mendonca Insurance Services
949.954.4445
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PLEASE COMPLETE THE INFORMATION BELOW FOR THOSE EMPLOYEES WHO ARE LIKELY TO PURCHASE LONG-TERM CARE INSURANCE.

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C Corp.
S Corp.
LLC
Partnership
Sole Proprietorship
Dental
Vision
Life
Short-Term Disability
Long-Term Disability
Group Health Insurance
Critical IIlness
401k / Retirement Plan