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Welcome to our team!

Agent Interest and Information Questionnaire

Thank you again for your interest in LTCCASH.com! Before we begin working together, we need some background information about you and your agency so that we can better assist you. Please take a moment to complete the following questionnaire so that we can follow up with you in a timely manner. We look forward to working with you in the very new future.

*ALL STARRED form fields are REQUIRED*

*Agent Name

Agency Name

*Email

*Best Number to Reach You

City

*State

Zip Code

Please Answer the Following Questions:

1. What does your general practice specialize in?

Group Yes No

Individual Yes No

Group & Individual Yes No

2. Number of LTC policies you sold last year

3. Number of LTC life plans you sold last year

4. Number of LTC annuities you sold last year

5. Would you like to receive leads?

Yes No

6. What kind of leads - Individual or Group?

Group Yes No

Individual Yes No

7. Would you be willing to move your current contract over to us?

Yes No

8. Do you currently have groups (health, life, etc.) on the books?

Yes No

9. Which LTC companies are you currently licensed with?

Genworth

MetLife Insurance

Prudential

Great American

MedAmerica

Allianz

Other

The information you provided will give us a much better idea how we can work with you.

Thank you for taking the time to complete this questionnaire. An LTC representative will be contacting you shortly to discuss the contracting options that LTCCASH.com offers. If you do not hear from us within 48 hours, please give us a call directly at 1.800.848.5080.