Long-Term Care Insurance Quote Request Form

Financial Advisor Name*

First Last

Email*

Preferred Phone #*

By when do you need the illustration / proposal?

Email address(es) for others who should be cc'ed with our reply:

APPLICANT INFORMATION

Applicant Name

First Last

Date of Birth

Risk Class

Preferred

Standard

Rated

Marital Status

Married

Single

State of Residence

Height

Weight

Has applicant ever used tobacco?

Yes

Specify type & date of last use

Prior Applications - please list prior applications with carrier, dates, and underwriting outcome:

Medications

Medical History

SPOUSE COVERAGE

Spouse Name

First Last

Spouse Date of Birth

Spouse Risk Class

Preferred

Standard

Rated

State of Residence

Height

Weight

Has applicant ever used tobacco?

Yes

Specify type & date of last use

Prior Applications - please list prior applications with carrier, dates, and underwriting outcome:

Spouse Medications

Spouse Medical History

LONG TERM CARE POLICY DESIGN

Benefit Amount

Spouse Coverage Options

Two Individual Policies

Survivorship / Joint Lives

Maximum Annual Premium

Benefit Payment Options at Time of Claim

Tax-free cash benefits that can be used for any purpose, including paying family, friends, or neighbors, without restrictions.

Tax-free benefits that limit benefits to professional care, or care in an institutional setting.

Show me both cash indemnity and professional care only policy options.

Elimination Period(s)

Benefit Period(s)

Inflation Rider Type and Percentage

Riders: Shared Care, Return of Premium, Restoration of Benefits, Waiver of Premium, Other - please specify):

Design Instructions (e.g. Survivorship / Joint Lives Option)

Do you have other information we should know as we develop proposals?

EXPERT HELP IS AVAILABLE

Do you focus on investments or other lines of insurance? Would you prefer not to have to invest time studying LTC policy variants? Help is available! We can introduce you to an LTC Insurance Expert. They are familiar with policy options and how clients can leverage the tax code to their maximum advantage. Once the Expert understands what your client is trying to accomplish, they will guide them toward a policy design and benefit payment option that’s right for them - and within their budget. Expert services are provided on a joint work basis, negotiated between you and the Expert.

Would you like to talk to a LTC Expert to strategize regarding a joint work arrangement?

Yes

Tell me more about how that might work

Upload Exams, Lab Results, HIPAAs etc.

Max. file size: 50 MB.

APPLICANT INFORMATION

SPOUSE COVERAGE

LONG TERM CARE POLICY DESIGN

EXPERT HELP IS AVAILABLE

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