Minnesota Long Term Care Insurance Quote

**Information received from this Minnesota Long Term Care Insurance quote
request form sent to the Baecker Insurance Agency 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 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 Minnesota Long
Term Care Insurance policy. We are licensed in Minnesota and Wisconsin and
will not provide long term care insurance quotes for other states.

We are your local St. Paul, Minnesota insurance agency, offering
affordable Long Term Care Insurance policy premiums in the
following Twin Cities area towns and counties: Minneapolis,
Bloomington, Roseville, Maplewood, North St. Paul, Oakdale,
Woodbury, Cottage Grove, South St. Paul, Inver Grove Heights,
Eagan, West St. Paul, Richfield, Burnsville, Edina, Lilydale,
Mendota Heights, St. Paul Park, Lake Elmo, Newport, Cedar
Grove, Savage, Shakopee, Eden Prairie, Minnetonka, Hopkins, St.
Louis Park, Plymouth, Golden Valley, Columbia Heights, New
Hope, Crystal, Robbinsdale, Brooklyn Center, Fridley, New
Brighton, Maple Grove, St. Anthony, Arfen Hills, Shoreview,
Vadnais Heights, Little Canada, White Bear Lake, Mahtomedi,
Grant, Bellaire, North Oaks, Gem Lake, Mounds View, Lino
Lakes, Blaine, Coon Rapids, Spring Lake Park, Lexington, Afton,
Lakeland, Bayport, Stillwater, Apple Valley, Andover, St. Cloud,
Mankato, Rochester, Duluth, Anoka, Champlin, Andover, Oak
Grove, St. Michael, Hanover, Scandia, Forest Lake, Wyoming,
Rosemount, Hastings, Vermillon, Coates, Ramsey County,
Hennepin County, Dakota County, Anoka County, and Washington
County, MN. We also offer long term care insurance services in
the remainder of Minnesota and throughout Wisconsin.

Full Name:
Mailing Address:
City:
State: (Minnesota or Wisconsin)     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

Coverage requested for?
Daily Benefit Amount: $
Benefit Period:
Elimination Period:
Payment Mode:

Do you own or rent your primary residence?
What amount do your current assets total?

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:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Spouse Information

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:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Medication Name:
Dosage: Frequency:
Reason/Condition:

Additional Information or Comments

Click on the "Submit Quote Information" button below to send
your Minnesota Long Term Care Insurance quote request.**