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Long Term Care Proposal

Please submit a request for proposal using the form below. We will begin to process your request immediately.

Please provide us with as much information as possible, so we can insure that your quote will be processed accurately and in a timely manner.

 Producer Information
  
Name:
Phone:
(area) (xxx-xxxx)
Fax:
(area) (xxx-xxxx)
Email:

All proposals and product information will be sent to you by email unless we are instructed otherwise.

 
 Client 1 Information:
 
Name:
Birth Date: / /
(mm/dd/yyyy)
Gender: Male Female
Residential Status: Married Single Partner Shared Residence
State of Residence:
Tobacco Use: Yes No
 
Medical Information
 
Medications and Dosages:
Medical History:
Underwriting Class Requested Preferred Standard
Other
Height:
Weight:
Has this client applied for, been issued or been declined for LTCi in the past? Yes No
Details:
 Client 2 Information:
 
Name:
Birth Date: / /
(mm/dd/yyyy)
Gender: Male Female
Residential Status: Married Single Partner Shared Residence
State of Residence:
Tobacco Use: Yes No
 
Medical Information
 
Medications and Dosages:
Medical History:
Underwriting Class Requested Preferred Standard
Other
Height:
Weight:
Has this client applied for, been issued or been declined for LTCi in the past? Yes No
Details:
 
 Illustration:
 
Coverage Requested: Reimbursement Indemnity Cash
State of Policy Issue:
1 2 3 4 5 6 7 10 Lifetime
Benefit Design: Monthly Daily
Benefit Amount:
Home Healthcare: 0% 50% 75% 100%
Elimination Period: 0 Days 20/30 Days 50/60 Days 90/100 Days 180 Days 365 Days
Inflation Riders: None CPI Simple Compound 3 Compound 5
Additional Riders:
Regular Payment Modes: Annual Semi-Annual Quarterly Monthly
Limited Payment Plans:
Is this a partnership case?: Yes No
Special Instructions:
 
Carrier Selection
 
Would you like us to suggest the one carrier we feel provides the best value for your client? Yes No

(If you select NO, multiple quotes will be provided)

 
An Illustration cannot be provided unless this form is completely filled out.