Applicant Information

First Name:

Last Name:

Address:

City:

SOUTH CAROLINA

Zip Code:

Daytime Phone:

Cell Phone:


Email:  (Required)


How Best To Contact You:
Select One Cell Phone Daytime Phone Email


Currently Insured:
Select One Yes No


Are you currently taking or have
you taken any prescription or
over-the-counter medications
during the last 12 months:


Select One Yes No



Insurance Information

Date of Birth:

Gender:
Select One Female Male
Height:

Weight:


Do You Smoke:
Select One Yes No

Do you currently own Long:
Term Care Insurance:
Select One Yes No

If Yes, what is your monthly premium:
$



Choose Coverage Limits

Coverage For:
Select One Applicant Applicant & Spouse Others

Type of Coverage Needed:
Select One Accident Only Health Only Accident & Health

Daily Benefit Amount Desired:
Select Amount $100 $150 $200 $300 $400 $500

Benefit Period:
Select One 1 year 3 years 5 years lifetime

Elimination Period:
Select One None 90 days 190 days 1 year

Payment Mode:
Select One Annual Semi-Annual Quarterly Monthly



Asset Information

Own or rent your primary residence:
Select One Yes No

Your current assets total:
Select One $50,000 to $100,000 $100,000 to $200,000 $200,000 to $500,000 $500,000 to $1 million Over $1 million



Question or Message:




Click the "Submit Quote Request"
button below to send your South
Carolina Long Term Care Insurance
request to Russell-Massey & Company.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***








We are a Columbia, SC insurance
agency offering South Carolina
long term care insurance quotes
in the following towns, cities and
counties in South Carolina:
Chapin, Arthurtown, Saluda, Terrace,
Sandwood, Arcadia Lakes, Cayce,
Olympia, Forest Acres, Dentsville,
Eau Claire, West Columbia, Springdale,
Denny Terrace, Belmont, St. Andrews,
Irmo, Oak Grove, Lexington, Galaxy,
Bluff Estates, Hazelwood Acres, State
Park, Haskell Heights, Lincolnshire,
Ballentine, Killian, Red Bank, South
Congaree, Edmund, Gilbert, Summit,
Gaston, Hopkins, Capitol View, Horrel
Hill, Fort Jackson, Pontiac, Elgin,
Blythewood, Camden, Richtex,
Whitehall, White Rock, Sumter, Lugoff,
Boykin, Rembert, Hagood, Horatio,
Stateburg, Borden, Wedgefield, Oswego,
Gadsden, Fort Motte, St. Matthews,
Swansea, Woodford, Winnsboro, Pelion,
Steedman, Samaria, Monetta,
Batesburg-Leesville, Stoney Hill,
Prosperity, Newberry, Peak, Little
Mountain, Slighs, Pomaria, Jenkinsville,
Rion, Winnsboro Mills, Simpson,
Smallwood, Ridgeway, Orangeburg,
Lexington County, Fairfield County,
Calhoun County, Sumter County,
Kershaw County, Saluda County,
and Richland County, SC. We can
also offer a South Carolina long term care
insurance quote throughout the Palmetto
state, including in Florence, Greenville,
Spartanburg, Myrtle Beach, and
Charleston, SC.

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