LTC Quote

Long-Term Care Insurance Quote Request
Agent/Advisor Information
Agent/Advisor Name*

First NameLast Name
E-Mail*
Phone Number*
Agent/Advisor State*
Client Information
Client Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Clients State*
Married?*

yesno
Living Alone?*
additional information
Medical Information
Height:
Weight:
Current Medications and Dosage?*
Hospitalizations in the past five years? If so, provide reasons and dates:*
Do you use a cane, walker or wheelchair? If so, indicate device and frequency:*
Have you used tobacco in the past 5 years? if you have quit, how long ago?*
Have you ever been diagnosed with cancer? if so, indicate type and stage:*
Do you have or had any history of any of the following:*

Memory loss or cognitive deficiencyHeart DiseaseDiabetesOsteoporosisFracturesArthritisStroke or TIAMuscular, Skeletal Madical ProblemsDizzinessFalls or ImbalanceNone
Diabetes or Arthritis type? Note any neuropathy or retinopathy for diabetes:
Policy Design
Daily Benefit:
Benefit Period:*
Elimination Period*

30 days60 days90 days1 year
Show Premiums as:*

MonthlyQuarterlySemi-AnnualAnnual
Inflation Option:*

None3%5%SimpleCompound
Show Hybrid Products?

YesNo
Include Life insurance? if yes how much?
Single Pay Premium?

50K75K100KOther
Additional Notes or Preferences on Benefits:
For questions please call 317-663-0061
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Long-Term Care Insurance Quote Request