New Jersey Long Term
Care Insurance Quote
We provide affordable Long Term Care Insurance
policy services throughout New Jersey!
Your Life Solutions of
Long Valley, NJ offers
affordable and
experienced personal
insurance services
throughout New Jersey.
Contact us about Auto,
Homeowners, Health,
Motorcycle, Renters,
and Boat Insurance.

In addition to Long Term
Care Insurance, we also
offer affordable New
Jersey Auto Insurance
policy premiums.
We are your local northern New Jersey insurance agency, offering affordable long term
care insurance policy premiums to residents in the following cities and counties:
Succasunna, Boonton, Boonton Township, Brookside, Budd Lake, Butler, Cedar
Knolls, Chatham, Chester, Convent Station, Denville, Dover, Dover Annex, East
Hanover, Fayson Lakes, Flanders, Florham Park, Gillette, Green Village, Greystone
Park, Hibernia, High Crest, Ironia, Kenvil, Kinnelon, Lake Hiawatha, Lake Hopatcong,
Lake Intervale, Landing, Ledgewood, Lincoln Park, Lindy Lake, Long Valley, Lower
Montville, Lyonsville, Madison, Mendham, Meriden, Millington, Mine Hill, Montville,
Montville Township, Morris Plains, Morristown, Mount Arlington, Mount Freedom, Mount
Olive, Mount Tabor, Mountain Lakes, Netcong, New Vernon, Parsippany, Pequannock,
Pequannock Township, Picatinny Arsenal, Pine Brook, Pinebrook, Pompton Junction,
Pompton Plains, Powerville, Ralston, Randolph, Riverdale, Rockaway, Rockaway
Valley, Schooleys Mountain, Stirling, Tabor, Taylortown, Towaco, Troy Hills, Wharton,
Whippany, Stanhope, Hopatcong, Espanong, Hurdtown, Cranberry Lake, Andover,
Greendell, Woodport, Springdale, Oak Ridge, Milton, Sparta, Lake Lenape, Newton,
Ogdensburg, Saxton Falls, Johnsonburg, Allamuchy, Vienna, Hackettstown,
Beattystown, Marksboro, Hope, Townsbury, Washington, Newark, Elizabeth, Rahway,
Colonia, Iselin, Avenel, Woodbridge, Port Reading, Carteret, Perth Amboy, Fords, South
Amboy, Metuchen, Plainfield, Dunellen, South Plainfield, Green Brook, Fanwood, North
Plainfield, Cranford, Scotch Plains, Westfield, Union, Millburn, Springfield,
Mountainside, Gillette, Warren, Watchung, Stirling, Millington, Middlesex, Martinsville,
Piscataway, Edison, New Brunswick, Highland Park, Somerset, Milltown, South River,
Bound Brook, Somerville, Bridgewater, Fairview, Ridgefield, Fort Lee, Leonia,
Palisades Park, Englewood Cliffs, Englewood, Bergenfield, Teaneck, Paramus,
Bogota, Ridgefield Park, Little Ferry, Hackensack, Maywood, Teterboro, South
Hackensack, Rochelle Park, Moonache, Lodi, Hasbrouck Heights, Saddle Brook,
Garfield, Elmwood Park, Woodridge, Carlstadt, East Rutherford, Lyndhurst, Rutherford,
Wallington, Passaic, Clifton, Paterson, Totowa, West Paterson, Little Falls, Great
Notch, North Caldwell, Cedar Grove, Verona, Montclair, Bloomfield, West Orange, Glen
Ridge, Belleville, Nutley, Kingsland, North Arlington, Kearney, Harrison, East Orange,
East Newark, Orange, Irvington, South Orange, Hillside, Townley, Livingston, Wayne,
Morris County, Sussex County, Somerset County, Pasaic County, Bergen County,
Hunterdon County, Union County, and Warren County, NJ. We also offer long term care
insurance services throughout the state of New Jersey, including the greater New York
City area.
Full Name:           
Mailing Address:
City:
State:  (New Jersey or New York)
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:
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

New Jersey 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 Quote Information" button below to send
your New Jersey Long Term Care Insurance quote request.**


**Information received from this New Jersey Long Term Care Insurance quote request form sent to Your Life Solutions, 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 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 New Jersey Long Term Care Insurance Policy. We are licensed in New Jersey, New York, and will not provide quotes for other states.


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