ICA Long-Term Care Illustration Intake Form

Long-Term Care Quote Request
ADVISOR INFORMATION
Advisor Name for Illustration*

First NameLast Name
Telephone #*
Email Address*
example@example.com
CLIENT INFORMATION
Client Name*

First NameLast Name
Client DOB*
Gender

FemaleMale
Insured State of Residence *
Marital Status*

MarriedDomestic PartnerSingle
Rating*

Preferred TobaccoStandard TobaccoPreferred Non-TobaccoStandard Non-Tobacco
Type of Policy*

Traditional Long-Term CareLife Insurance with Long-Term CareHybrid LTC (ex- MoneyGuard, CareMatters)Annuity with Long-Term Care
Do you have a preferred carrier(s)?
Daily/Monthly Benefit Amount to Solve for Premium (If solving for Benefit Enter 0)*
Example $200 day/ $6,000 monthly
Premium Amount to Solve for Benefit (If Solving for Premium Enter 0) *
Example Single Pay $100,000 10 Pay $10,000- Or Continuous Pay
Premium Payment Duration*

Single Pay10-Pay20-payContinuousOther
Benefit Period (How many years would you like benefits?)*
Typical benefit durations are 2/4/6/ Max years
Would you like inflation protection? (Select 1 option below)*

No3% Compound3% Simple5% Compound5% Simple
If Joint Quote (Shared Policy) is needed, please provide spouse/partner's information
First/ Last Name, Date of Birth, Gender, Health Rating desired
Additional Notes / Possible Client Health Issues
When is your meeting with the client(s)?*

MonthDayYear
Date
ICA Insurance Services are administered by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers LLC in California #0795478. Coverage is subject to actual policy terms and conditions. Policy benefits are the sole responsibility of the issuing insurance company.
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Long-Term Care Quote Request

ADVISOR INFORMATION

CLIENT INFORMATION