Full Name:           
Mailing Address:
City:
State:  South Carolina
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:       Cell Phone:
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

South Carolina 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 Insurance Quote Request" button below to send
your South Carolina Long Term Care Insurance quote request.**


**Information received from this South Carolina Long Term Care Insurance quote request form sent to Russell-Massey & Company 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 South Carolina 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 South Carolina Long Term Care Insurance policy. We are licensed in South Carolina and will not provide long term care insurance quotes for other states.


South Carolina Long Term
Care Insurance Quote
Russell-Massey & Co.
of Columbia, SC offers
affordable and
experienced personal
insurance coverage
services throughout
South Carolina.
Contact us about South
Carolina Auto, Renters,
Homeowners, Boat,
Motorcycle, Disability,
and Health Insurance toll
free at (800) 849-7475.
In addition to South
Carolina Long Term Care
Insurance quotes, we also
offer affordable Life
Insurance quotes.
We are a Columbia, SC insurance agency offering affordable South
Carolina long term care insurance policy quotes in the following
towns, cities and counties in South Carolina: Chapin, Arthurtown,
Saluda Terrace, Sandwood, Arcadia Lakes, Cayce, Olympia, Forest
Acres, Dentsville, Eau Claire, West Columbia, Springdale, Denny
Terrace, Belmont, St. Andrews, Irmo, Oak Grove, Lexington,
Galaxy, Bluff Estates, Hazelwood Acres, State Park, Haskell
Heights, Lincolnshire, Ballentine, Killian, Red Bank, South
Congaree, Edmund, Gilbert, Summit, Gaston, Hopkins, Capitol
View, Horrel Hill, Fort Jackson, Pontiac, Elgin, Blythewood,
Camden, Richtex, Whitehall, White Rock, Sumter, Lugoff, Boykin,
Rembert, Hagood, Horatio, Stateburg, Borden, Wedgefield,
Oswego, Gadsden, Fort Motte, St. Matthews, Swansea, Woodford,
Winnsboro, Pelion, Steedman, Samaria, Monetta, Batesburg
Leesville, Stoney Hill, Prosperity, Newberry, Peak, Little Mountain,
Slighs, Pomaria, Jenkinsville, Rion, Winnsboro Mills, Simpson,
Smallwood, Ridgeway, Orangeburg, Lexington County, Fairfield
County, Calhoun County, Sumter County, Kershaw County, Saluda
County, and Richland County, SC. We can also offer cheap South
Carolina long term care insurance coverage quotes throughout the
Palmetto state, including in Florence, Greenville, Spartanburg,
Myrtle Beach, and Charleston, SC.
Applicant Information:
Your South Carolina
Long Term Care Insurance
Quote Source
Russell-Massey & Co.
1320 Elmwood Avenue
Columbia, SC 29201
Richland County, SC
Toll Free: (800) 849-7475
Office: (803) 779-7854
Fax: (803) 799-6546
Russell-Massey & Co.
409 Lexington Avenue
Chapin, SC 29036
Lexington County, SC
Office: (803) 941-3650
Fax: (803) 941-3654
We can offer affordable South Carolina Long Term Care Insurance
coverage in Columbia, SC and throughout the Palmetto State!
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South Carolina
Personal
Insurance Quotes
Long Term Care
Insurance Quote
Russell-Massey
& Company, Inc.
General Insurance
SC Long Term Care Insurance Quote!
800-849-7475 toll free
803-779-7854
Serving South Carolina Since 1955
Richland County & Lexington County, SC Area
Richland County & Lexington County, SC Area