New York Partnership for Long Term care


Request a New York Partnership Long Term Care Insurance Quote

To request a Long Term Care Insurance quote, please complete this form entirely. Or, if you prefer, call our offices at (818) 597-3227 for confidential information from an Association staff member.
All information on this form is confidential and is forwarded directly to an agent that serves your area.

PLEASE NOTE: LTC Insurance quotes generally require a discussion of converges, needs and evidence of insurability. If you have no intentions of speaking with a professional agent, please do not complete this form. Thank you.

* = Required Information

*   Who are you requesting this quote for:

*   E-mail address:

*   First Name: , of the person to be protected.
*  Last Name:
*  Date of Birth:
*  Health Conditions:

*  Use of tobacco products within the past three years? Yes No

Please fill out this area ONLY if there is an insuree spouse / companion / partner.

First Name:
Last Name:
Date of Birth:
Health Conditions:

Use of tobacco products within the past three years? Yes No

*   Contact Information:

*  Street Address:
*  City:
*  State:
Zip Code:
*  Phone:
Best time to call:
Preferred Contact:

*  To better meet your needs please answer these few additional questions:

Would you be willing to answer health questions to an insurance agent? Yes No

If Long-Term Care Insurance meets your expectations, and fits in your budget; do you plan on enrolling in the next 60 days? Yes No

Do you currently own a Long-Term Care Insurance Policy? Yes No

*  What is the reason for you seeking LTC Coverage?

If you have chosen other, please provide your reason for seeking LTC coverage:

How did you find us?

Additional Comments:

Leave this empty to help prevent automated form submissions:


NY Long Term Care Partnership Only - is your complete source for the NY LTC Insurance Partnership Program. Learn all you need to know about the LTC Partnership Program and request LTC Insurance quotes today on the top LTC Insurance carriers. NY LTC covers USA only. NY Long Term Care - NY LTC - New York LTC Partnership - NY Long Term Care.

This is a solicitation of insurance. By filling out this request for quote, you are requesting a licensed insurance agent to contact you by telephone.

Valuable Resources

  Request Long Term Care Insurance Quote - 20% State tax Credit - About Long Term Care Insurance - NYSP for Long Term Care Website - Elder Law Attorneys - Other Partnership Websites - Site Map - Disclosure - Home