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Long-Term Care Quote Request

Agent Information

1. Agent Name *
2. Address
3. City
4. State -- Select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist 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
5. Zip Code
6. Phone *
7. E-mail *
8. Return Method

   Mail Email Fax

Client Information

1. Agent Name
2. State -- Select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist 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
3. Date of Birth
4. Return Method

   Married Single
5. Rate Class

   Preferred Standard Sub-Standard
6. List all meds, dosage, reason, and any medical treatment
in the last 5 years:
7. Spouse Name
8. Date of Birth
9. Rate Class

   Preferred Standard Sub-Standard
10. List all meds, dosage, reason, and any medical treatment
in the last 5 years:

Click from the following options

1. Option A
   • Option A 3-yr benefit
   • 90-day elimination
   • 5% compound
   • HC-100%
   • Your state's ave
   • Monthly benefits
   Option B
   • 5-yr benefit
   • 90-day elimination
   • 5% compound
   • HC-100%
   • Your state's ave
   • Monthly benefits
   Option C
   • LT benefit
   • 90 day elimination
   • 5% compound
   • HC-100%
   • Your state's ave
   • Monthly benefits

   ---

2. Option D
3. Benefit Amount

   Daily Monthly Indemnity Cash
4. Home Health Care

   None 50% 75/80% 100% HHC Only
5. Elimination Period -- Select -- 20/30 45/60 90/100 180 365 730
6. Benefit Period -- Select -- 2 3 4 5 6 7 8 9 10 LTC
7. Inflation -- Select -- FPO/GPO 3% Simple 3% Compound 4% Compound 5% Simple 5% Compound Compound 2X None
8. Riders -- Select -- Shared Care Couple Survivorship Restoration of Benefits Spousal Waiver ROP-Less Claims ROP- regardless of Claims

Payment Options

1. Payment Plan -- Select -- Life Pay 5 Pay 10 pay 20 Pay Single Pay Pay to 65 Double Pay
2. Payment Mode

   Monthly Quarterly Semi-Annually Annually

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