Long Term Care

Broker Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Fax

Client Information

Client Name

First Last

Date of Birth

Risk Class

Preferred
Standard
Rated

Height

Weight

Has applicant ever used tobacco?

Yes
No

Specify type & date of last use

Medications

Medical History

Spouse Name

First Last

Spouse Date of Birth

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

Benefit Amount

Is this benefit amount:

Daily
Monthly

Marital Status

Married
Single

Elimination Period (days)

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

Long Term Care Quote

Client Information

Login Status

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