DAVEVIC..employee benefits, group hospitalization insurance, pension plans and commercial insurance.

Products Menu

"Finding Solutions
Beyond the Obvious"

1- 800-854-4099
724-458-7255
Fax: 724-458-7261
service@davevic.com

902 South Center Street
P.O. Box 976
Grove City PA 16127

Content copyright 2008

Please use this form to submit a quote request.
A licensed representative from our company will contact you about your request.

Long Term Care Quote

Proposed Insured

Spouse

First Name*

Last Name*

Birthday* (mm/dd/yyyy)

Street*

City*

State*

Zip Code*

Telephone*

Any Hospitalizations in past 5 years?

Yes No

Medications:

Tobacco User?

Yes No

If Yes, how long?

Please specify for each if either have been diagnosed/treated
in the past 10 years so we can provide an accurate quote

Alcoholism	Lupus	Neurogenic Bladder
Lou Gehrig’s Disease	Kidney Failure	Organic Brain Syndrome
Alzheimer’s	Memory Loss	Organ Transplant
Aneurysm	Epilepsy	Carotid Artery Disease
Cancer	Multiple Sclerosis	Osteoporosis w/ Fractures
Confusion/ Disorientation	Arthritis	Parkinson’s Disease
Congestive Heart Failure	Cerebral Vascular Disease	Peripheral Neuropathy
Dementia	Emphysema	Senility
Diabetes	Spine/Back Disorder	Stroke
Depression	Heart Attack	Macular Degeneration
Ulcerative Colitis

Agent Information

Name

Telephone

(555-555-5555)

EMail

Declaration: I confirm all the statements and particulars given above are
true and that I have disclosed all the facts relating to myself.

Maintained by: Keffer Development Services