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LTCI Quotes

For Mail or Fax Quotes

If you wish to Mail or Fax us for a quote please download, print and fill out the following two forms.

Once both forms are completely filled out you can send via the following methods:

FAX
MAIL
(650) 692-5204
Northstar Network,Inc.
P.O. Box 4007
Burlingame, CA 94011

For Web Based Inquiries

If you wish to submit a quote request via the internet please fill out the following form and click submit.

* = Required Field

Section 1 - Producer Information
* Producer
Address Line 1:
Address Line 2:
City, State and Zip:
* Email Address:
* Business Phone:
Cell Phone:

Section 2 - Applicant Information
Applicant's Name:
Applicant's Date of Birth:
 ex. 01/01/2004
Applicant's State of Residence:
Applicant's Sex:
 Male Female
Medications taken on a regular basis:
Quote a preferred class on the applicant?
 Yes No

Section 3 - Joint Applicant Information
Joint applicant's name:
Joint applicant's Date of Birth:
Joint applicant's State of Residence:
Joint applicant's Sex:
 Male Female
Medications taken on a regular basis:
Quote a preferred class on the joint applicant?
 Yes No

Section 4 - Quote Information
* State in which this
application will be signed
Company(s) requested:
Benefit Amount:
 $
Elimination Period:
Benefit period:
Inflation:
Quote Shared Care?
 Yes No
HHC amount:

HHC indemnity?
 Yes No
HHC waiver of Elimination Period?
 Yes No
Payment options
 Annual
Semi-Annual
Quarterly
Monthly
Pre-payment options
 10 Pay
Single Pay
Pay to 65
Return of premium:

Section 5 - Case Information
Are you in competition for this case?
 Yes
No
I Don't Know
If yes, please specify
Additional comments or health concerns?

 

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