ICA Long-Term Care Illustration Intake Form

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

First NameLast Name
Telephone #
Format: (000) 000-0000.
Email Address
example@example.com
CLIENT INFORMATION
Client Name

First NameLast Name
Client DOB
Gender
Insured State of Residence
Marital Status
Rating
Type of Policy
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

Other
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)
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 is supported by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers LLC in California (#0795478). Lockton Affinity provides access to insurance and annuity solutions, as well as sales and case management support to ICA Insurance Services.

ICA Insurance Services and Lockton Affinity are not affiliated companies.
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Long-Term Care Quote Request