Full Name:           
Mailing Address:
City:  
State: New Jersey, CT, PA or NY
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:       Cell Phone:
Date of Birth:              (mm/dd/yyyy)
Gender:    Height:  ft. 
Weight:    Do you smoke?
Do you currently have long term care insurance?
Current Premium:$  per month

Long Term Care Insurance Coverage Information:

Coverage requested for?
Daily Benefit Amount: $  
Benefit Period:      
Elimination Period:
Payment Mode:    

Asset Information:
Do you own or rent your primary residence?
What amount do your current assets total?   

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

If you answered "Yes" to the question above please
provide the necessary information below:

Medication Name:    Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:


Is Spouse to be insured?
Spouse: Full Name:     
Spouse Date of Birth:  (mm/dd/yyyy)
Spouse Gender:   Spouse Height:  ft. 
Spouse Weight:
Does your Spouse smoke?  
Is Spouse married to Applicant?

Is Spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please
provide the necessary information below:

Medication Name:   Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:

Additional Comments or Requests



Click on the "Submit Insurance Quote Request" button below to send your
New Jersey, CT, PA or NY Long Term Care Insurance quote request.**


**Information received from this Long Term Care Insurance quote request form
sent to W.R. McClure Insurance Services, Inc. will be for our use only and will
not be sold, given to or distributed to any other parties. A quote will be based
on the New Jersey, CT, PA, or NY long term care insurance policy information
provided and does not guarantee acceptance of the risk by us. The precise
coverage afforded is subject to meeting underwriting guidelines, and the terms,
conditions and exclusions of the policy as issued. By submitting this request you
acknowledge that this is neither an offer to insure nor a guarantee of insurance.
Completion of this form does not entitle you to a Long Term Care Insurance policy.
We are licensed in New Jersey, CT, PA, NY, and will not provide long term care
insurance quotes in other states.


Long Term Care
Insurance Quote
Applicant Information:
We offer affordable New Jersey
Long Term Care Insurance throughout
New Jersey, CT, PA, and NY!
W.R. McClure
Insurance Services
Large enough to answer client needs and small
enough to maintain personal relationships.
W.R. McClure
Insurance Services of
Flanders, NJ offers
affordable personal
insurance coverage
services throughout
New Jersey, CT, PA,
and NY.
Contact us about New
Jersey Auto, Renters,
Homeowners, Flood,
Umbrella, Long Term
Care, Motorcycle, and
Boat Insurance at
(973) 584-5850.

In addition to Long
Term Care Insurance
quotes for New Jersey,
CT, PA, and NY, we
also offer affordable
Homeowners Insurance
policy premium quotes.
New Jersey
Insurance Quotes
We are a Flanders, NJ insurance agency offering more affordable
New Jersey long term care insurance quotes to residents of the
following towns, cities and counties in New Jersey: Mount Olive,
Budd Lake, Hackettstown, Ledgewood, Succasunna, Naughright,
Chester, Mount Freedom, Randolph, Wharton, Dover, Beatyestown,
Port Murray, Great Meadows, Netcong, Mount Arlington, Hopatcong,
Mount Hope, Morristown, Rockaway, Morris Plains, Mendham,
Whippany, Parsippany, Boonton, Hurdtown, Espanong, Greendell,
Pottersville, Bernardsville, Basking Ridge, Mountainville, High
Bridge, Bunnvale, Hampton, Washington, Hope, Newark, Trenton,
Camden, Elizabeth, Jersey City, Paterson, Hackensack, Cherry Hill,
Vineland, Millville, Toms River, Atlantic City, Piscataway, Fort Lee,
Orange, Union City, Paramus, New Brunswick, Bayonne, Hoboken,
North Bergen, Essex County, Middlesex County, Mercer County,
Hunterdon County, Bergen County, Passaic County, Morris County,
Warren County, Sussex County, Somerset County, Union County,
Hudson County, Gloucester County, Camden County, Burlington
County, Atlantic County, Ocean County, Cumberland County, Salem
County, Monmouth County, and Cape May County, NJ. We also
provide long term care insurance quotes throughout Connecticut,
Pennsylvania, and New York.
Your New Jersey
long term care insurance
quote connection!
W.R. McClure
Insurance Services, Inc.
230 Route 206
Building 1 - Suite 8
Flanders, New Jersey 07836
Morris County, NJ
Office: (973) 584-5850
Fax: (973) 584-3440

W.R. McClure Insurance Services, Inc.
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