Integrated Benefits and Insurance Services, Inc.

Home

Employee Benefits

Life Insurance

Disability Income Protection

Individual Medical

Long Term Care

Travel Insurance

Integrated Benefits
and Insurance Services, Inc.
2400 22nd Street, Suite 100
Sacramento, CA 95818
(916) 457-0444 (800) 660-9006
E-Mail: info@integratedbenefits.biz
Web: www.integratedbenefits.biz
California License # 0629367

Click a company icon to apply online
	BLUE CROSS OF CA
	BLUE SHIELD OF CA
	HEALTH NET
	TRAVEL MEDICAL

Request a quote for Long Term Care Insurance

It's easy to get a quote for Long Term Care Insurance. To request a quote please complete the following:

Contact Information

Title:
First Name:
Last Name:
Date of Birth , Year (ex. 1950)
Street:
City:
State:
Zip Code:
Daytime Phone:
Evening Phone:
Best time to call:
E-mail:
Do you have an existing LTC Policy?	Yes No
Have you ever applied for a LTC Policy?	Yes No
Do you wish to include your spouse?	Yes No
If yes, please provide spouse's date of birth:	, Year (ex. 1950)
Is this information for:
Note: Integrated Benefits & Insurance Services Inc. is currently licensed in California only.

Have you had, do you have, or have you ever been treated for:

Alzheimer's disease? Dementia?	Yes No
Parkinson's disease or syndrome?	Yes No
AIDS, AIDS related complex (ACH)?	Yes No
Cancer?	Yes No
Multiple Sclerosis?	Yes No
Muscular Dystrophy?	Yes No
Diabetes?	Yes No
Heart attack, heart surgery, angina?	Yes No
Mental or nervous disorder (including depression)?	Yes No
Have you used tobacco products in the last 5 years?	Yes No
Stroke (DVA) within the last 5 years?	Yes No
Stroke with residual impairment?	Yes No
Transient ischemic attack (TIA) within last 5 years?	Yes No
Multiple transient ischemic attacks (TIA)?	Yes No
Congestive Heart Failure?	Yes No
Diabetes under treatment with insulin?	Yes No
Emphysema / Chronic Obstructive Pulmonary Disease (COPD)?	Yes No
Asthma?	Yes No
Do you use a Walker or Wheelchair, Oxygen, Respirator, Kidney Dialysis, or need assistance or supervision by another person in performing any of the following: Moving in /out of bed or chair, Bathing, Dressing, Eating, Toileting, Bowel / Bladder control, Walking?	Yes No