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Quote Request » Long Term Care

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential - please see our Privacy Policy. Use your Tab key to go forward and Shift+Tab to go back. Please do not hit "Enter" or click "Submit" until the form has been completed. If your client has serious health problems or unusual circumstances, please call (toll free) 877-254-4429 for a no-cost, confidential consultation.*Red = Required Field

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First Proposed INsured
Advisor:*
First Proposed Insured's Name:*
Sex:* M     F
DOB:*
Height:*    Weight:*
Tobacco Use:* yes    no
If yes, please list details:
Phone (work):
Phone (home):
Phone (cell):
Fax:
E-mail:
Address:
City:
State:*    Zip:
   
Health Details - First Proposed INsured
Have you been treated for or diagnosed with any of the following: (check all that apply) Diabetes
Liver Disorder
Asthma or Lung Disease
Elevated Blood Pressure
Cancer
Kidney Disorder
Elevated Cholesterol
Osteoarthritis/Osteopenia
Heart Disease
Rheumatoid Arthritis
Alcoholism or Drug Addiction
Elevated Liver Functions
Any history of anxiety, depression, psychological counseling? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Medications in the past 5 years? yes    no
If yes, please provide details below, including dates, details and reason:
Hospitalizations or Surgeries in past 10 years? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
   
Second proposed insured
None     Partner not applying
Second Proposed Insured's Name:*
Sex:* M     F
DOB:
Height:    Weight:
Tobacco Use:* yes    no
If yes, please list details:
   
Health Details - Second proposed insured
Have you been treated for or diagnosed with any of the following: (check all that apply) Diabetes
Liver Disorder
Asthma
Elevated Blood Pressure
Cancer
Kidney Disorder
Elevated Cholesterol
Osteoarthritis/Osteopenia
Heart Disease
Rheumatoid Arthritis
Alcoholism or Drug Addiction
Elevated Liver Functions
Any history of anxiety, depression, psychological counseling? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Medications in the past 5 years? yes    no
If yes, please provide details below, including dates, details and reason:
Hospitalizations or Surgeries in past 10 years? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
   
LTC Policy Benefit Options
Elimination Period* (days): 30   60   90   180   365
Inflation Coverage:* None   Simple   Compound
Home Care and Nursing Home
Daily Benefit:*		 $
Benefit Period* (years): 3   4   5   6   10 
Lifetime
Riders:
   
delivery options
Deliver quote by:*
(choose preferred method)

e-mail:

phone:

fax:

Date quote needed:*
  *Red = Required Field