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Long Term Care Quote Request
Broker Name
*
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Fax
Client Information
Client Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Risk Class
*
Preferred
Standard
Rated
Height
Weight
Has applicant ever used tobacco?
*
Yes
No
Has applicant ever used tobacco?
*
Yes
No
Specify type & date of last use
Medications
Medical History
Spouse Name
First
Last
Spouse Date of Birth
MM slash DD slash YYYY
Gender
*
Male
Female
Spouse Risk Class
Preferred
Standard
Rated
Height
Weight
Has applicant ever used tobacco?
Yes
No
Specify type & date of last use
Spouse Medications
Spouse Medical History
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
Benefit Amount
*
Is this benefit amount:
*
Daily
Monthly
Marital Status
*
Married
Single
Elimination Period (days)
*
30
60
90
180
365
Benefit Period (years)
*
Select One
2
3
4
5
10
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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