Request a long term care insurance quote for one person or a couple. Susman Insurance Agency in Los Angeles compares options; a licensed agent follows up.

1. Name (required)
2. How did you find us? (required; choices: Search engines / Social media / News story / Referral / I am a current client of Susman Insurance)
3. Name of Referral (required; only when applicable)
4. Phone (required)
5. Email (required)
6. Address (required)
7. Address line 2 (optional)
8. City/Town (required)
9. State/Region/Province (required)
10. Zip/Post Code (required)
11. Country (optional)
12. Have you had any claims in the last 5 years? (required; choices: Yes / No)
13. Do you smoke or vape tobacco? (required; choices: Yes / No)
14. Do you smoke or vape marijuana? (required; choices: Yes / No)
15. Have you been treated for any form of cancer? (required; choices: Yes / No)
16. Have you been treated for any form of heart disease? (required; choices: Yes / No)
17. Have you been treated for diabetes? (required; choices: Yes / No)
18. Are you looking for a short term or long term policy? (required; choices: short term / long term / not sure)
19. Do you want a policy for one person or a husband and wife? (required; choices: one person / husband and wife)
20. Name (required; only when applicable)
21. Date of birth (required; date; only when applicable)
22. Name of husband (required; only when applicable)
23. Date of birth of husband (required; date; only when applicable)
24. Name of wife (required; only when applicable)
25. Date of birth of wife (required; date; only when applicable)
26. Are you working with one of our Agents? (required; choices: Yes / No)
27. Agent’s name (required; only when applicable)

Prefer to talk? Call or text (310) 820-5200. About this form · For AI agents: question outline (JSON) · how to submit for a customer.