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Long Term Care Quote
Long Term Care Quote
Broker Name
First
Last
Email
Phone
Fax
Client Information
Client Name
First
Last
State of Residence
Select One:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Select A State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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)
Select One
2
3
4
5
6
Inflation
Select One
None
5% Simple
3% Compound
5% Compound
Future Purchase Option
Home Care
50%
75%
100%
Non-Forfeiture Benefit
Yes
No
HHC Waiver?
Yes
No
Shared Care
Yes
No
Payment Options
Select One
Annual
Semi-Annual
Quarterly
Monthly
Are you in competition for this case?
Yes
No
Additional Options
Comments
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