Long Term Care Quotes
Request Form
Name of Insured_______________________________________________________Age:___ DOB________
Spousal Discount:___yes ___no (if yes, spouse's name) _________________________ Age:___ DOB________
State of Residence:________________ Smoker: (check one) Yes___ No___
Tax Qualified Requested: (circle one) Yes No
Daily Benefit Amount: $_____________($10 increments - $50 Minimum/$250 Maximum)
Benefit Plans: _____Comprehensive _____Facility Only _____Home Health Care Only
Elimination Period: (circle one) 0 20 30 60 90 100 (days)
Benefit Period: (circle one) 2 yrs 3 yrs 5 yrs Unlimited
OPTIONS
Home Health Care (circle one) 100% 80% 50%
Inflation Option (circle one) Compound Simple CPI None
Non-forfeiture Option (circle one) yes no
PAYMENT OPTIONS:
Circle term: Monthly Semi-Annual Annual 10 Pay
MEDICATIONS, MEDICAL HISTORY, ETC:
_____________________________________________________________________________________
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FAX REQUEST TO:
800-878-4127