14 East Highland Avenue | Philadelphia, Pennsylvania U.S.A. 19118

Chestnut Hill Community Association (CHCA)
Long Term Care Quote Request Form

Please take a few moments to complete this request form.
We will provide a complementary and customized long term care insurance review and quote.
Contact Information
contact name
e-mail address
mailing address


city state zip
phone fax
best way to contact you
best time to contact you
Personal Information about the applicant(s)
Applicant* question mark
name of applicant
date of birth / /
state of residence
marital status
*relationship to contact name
parent sibling aunt uncle grandparent child in-law
Spouse / Partner / Co-Applicant
date of birth / /
state of residence
relationship to applicant
Coverage Choices
Daily Benefit question mark
Benefit Period question mark
Waiting Period question mark
Inflation Protection question mark
Spouse / Partner / Co-Applicant
Health Information
Please answer these easy questions to help determine your eligibility with different insurance companies.
The information will remain confidential and private and will only be used to evaluate the available options.

In the past 3 years, have you used tobacco products including cigarettes, pipe, cigar, or chewing tobacco?
Applicant: yes no Co-Applicant: yes no

During the past 5 years, have you been confined to a hospital, nursing home, or received nursing care at home?
Applicant: yes no Co-Applicant: yes no

Please list current medications and the condition they are treating:



Applicant Height Weight Co-Applicant Height Weight

Please tell us how you found our website.

select one:

Internet Search  
current Hirshorn Company client  
CHCA website  
Chestnut Hill Local  
CHCA event  
Golf Styles magazine  


We will respond in 2 business days and provide the requested quote.
Long Term Care Insurance is not available in every state.
LTCI requires an application and is individually underwritten by a licensed insurance company.

Please read this important information and our privacy policy.