NYLifeandHealth.com offers low cost term and whole life insurance for new york
  life insurance, medicare supplements, and long term care from NYLifeandHealth.com

Our Life Products
Will Provide:

Life Insurance Coverage for funeral, burial and final expenses.

Proceeds to be used for any purpose at beneficiary's discretion.

Many companies available - we do the shopping for you!

Depending on your health, Many Guaranteed Issue Plans available.

Many life policies can build up cash value.

Many convenient payment plans avaialable.

NYLifeandHealth.com offer free life insurance facts, click here to view

Get Quotes On Our
Other Products Too:

Medicare Supplement Quote

Long Term Care Quote

 
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Life Insurance New York
Norton & Siegel, Inc.
Insurance With Service Since 1892!

 

 
On-Line Long Term Care
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be New York)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Are You Looking For
Spouse Coverage?

Yes No
 
Health Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/C)


UNDERWRITING INFORMATION
 
Insured Name: Birthdate:
Insured Height: Insured Weight:
Insured Occupation: Sex (M/F):
 
Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!
Do You use tobacco? Yes No Describe usage (cigar, cigarettes, etc.)
 
Any Pre-existing Health Conditions?
(If yes, descibe in detail, and to which of the insured persons they apply.)
 
Any Covered Persons Currently Taking Medication of Any Kind?
(If yes, descibe in detail, and to which of the insured persons they apply.)


COVERAGE INFORMATION
 
How Long Do You Need Coverage For?
(1 Year, 5 Years, Lifetime, etc.)
 
What Daily Benefit Amount Needed? (In Dollars $)
 
What Waiting Period Do You Want?
(30 days, 60 days, 90 days, etc.):
 
Any special coverages needed?
(Such as Home Health Care Cov., Compound Inflation Rider, etc.)
 
Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:


Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me My
Long Term Care Quote NOW!


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Norton & Siegel, Inc. | PO Box 220 | Babylon, NY 11702
Phone: 1-631-669-0365 | Fax: 1-631-669-0158
Life Insurance New York
Terms of Use/Privacy Notice/Copyright Info.   | Design 2012 Insurance-Web-Sales
More About Our Agency | Please report questions/problems to: sales@nortonandsiegel.com

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