LONG TERM CARE QUOTE REQUEST

LONG TERM CARE QUOTE REQUEST
Please complete all sections prior to submission. Incomplete information will result in inaccurate assessments for insurance carriers.
Producer Information
Name
LTC Training Complete

YesNo
Email Address
example@example.com
Phone Number
Address
Quote Needed By

MonthDayYear
Date
Client Information
Client Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Height
Weight
Marital Status

MarriedSingle
State
Tobacco Use

YesNo
Last Used

Medical History

	Diagnosis	Date of Onset	Date of Last Symptom	Medications

Long Term Care Benefits
Desired Benefit Amount
Frequency

DailyMonthly
Home Health Care Percentage
Elimination Period # of days
Benefit Period

2 Year3 Year4 Year5 Year6 Year
Inflation Protection

None3% Compound4% Compound5% Compound
Additional Riders

Shared Care/BenefitsRestoration of BenefitReturn of PremiumZero-day Home Elimination Period
Target Annual Premium
Partnership Plan Requested?

YesNo
Should be Empty:

Producer Information