Long Term Care Quote

Broker Name
First Last
Email
Phone
Fax
Client Information
Client Name
First Last
State of Residence
Date of Birth
MM slash DD slash YYYY
Marital Status
- Single
- Married
- Domestic Partner
If married, how long?
If Domestic Partner, how long?
Risk Class
- Preferred
- Standard
Height
Weight
Tobacco use last 5 years? Yes/No, Quit Date.
- Yes
- No
Quit Date:
Medications, amount, usage, and reason:
Health Conditions, Diagnosis and Dates:
Business Owner?
- Yes
- No
If yes, choose one of the following business types:
- "C" Corp
- "S" Corp
- Self Employed
Spouse Name
First Last
Spouse State of Residence
Spouse Date of Birth
MM slash DD slash YYYY
Spouse Risk Class
- Preferred
- Standard
Height
Weight
Tobacco use last 5 years? Yes/No, Quit Date.
- Yes
- No
Quit date
Spouse Medications, amount, usage and reason:
Health Conditions, Diagnosis and Dates:
Benefit Amount
Is this benefit amount:
- Daily
- Monthly
Choose Carrier
- Genworth
- John Hancock
- Mass Mutual
- Mutual of Omaha
- Transamerica
Elimination Period (days)
- 30
- 60
- 90
- 180
- 365
Benefit Period (years)
Inflation
Home Care
- 50%
- 75%
- 100%
Non-Forfeiture Benefit
- Yes
- No
HHC Waiver?
- Yes
- No
Shared Care
- Yes
- No
Payment Options
Are you in competition for this case?
- Yes
- No
Additional Options
Comments

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Client Information