Long Term Care Insurance Quote Request

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First Proposed INsured
First Proposed Insured's Name:*
Sex:* M     F
DOB:*
Height:*   Weight:*
Tobacco Use:* Never
Cigarettes - Number per day:
Cigars - Number per day:
Other, please list details:

Date of last use:
Phone (work):
Phone (home):
Phone (cell):
E-mail:
Address:
City:
State:*    Zip:
   
Health Details - First Proposed INsured
Have you been treated for or diagnosed with any of the following:(check all that apply) Diabetes
Liver Disorder or Elevated Liver Functions
Asthma or Lung Disease
Elevated Blood Pressure
Cancer
Blood Disorder
Dizziness or Vertigo
Alzheimer's or other Cognitive Disorder
Back or Spine Disorder
Bone or Joint Disorders
Kidney Disorder or Abnormal Kidney Tests
Elevated Cholesterol
Osteoarthritis/Osteopenia
Heart Disease or Heart Attack
Rheumatoid Arthritis
Alcoholism or Drug Addiction
Any history of anxiety, depression, psychological counseling? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Current Medications: yes    no
If yes, please provide details below, including dates, details and reason:
Hospitalizations or Surgeries in past 10 years? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Are you currently receiving Disability Payments? yes    no
If yes, please provide date payments began and reason:
Are you currently using any Assistance Devices? yes    no
If yes, what device and how long?:
   
Second proposed insured
None     Partner not applying
Second Proposed Insured's Name:*
Sex:* M     F
DOB:
Height:   Weight:
Tobacco Use:* Never      Date of last use:
   
Health Details - Second proposed insured
Have you been treated for or diagnosed with any of the following: (check all that apply) Diabetes
Liver Disorder or Elevated Liver Functions
Asthma or Lung Disease
Elevated Blood Pressure
Cancer
Blood Disorder
Dizziness or Vertigo
Alzheimer's or other Cognitive Disorder
Back or Spine Disorder
Bone or Joint Disorders
Kidney Disorder or Abnormal Kidney Tests
Elevated Cholesterol
Osteoarthritis/Osteopenia
Heart Disease or Heart Attack
Rheumatoid Arthritis
Alcoholism or Drug Addiction
Any history of anxiety, depression, psychological counseling? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Current Medications: yes    no
If yes, please provide details below, including dates, details and reason:
Hospitalizations or Surgeries in past 10 years? yes    no
If yes, please provide details below, including dates of diagnosis and treatment:
Are you currently receiving Disability Payments? yes    no
If yes, please provide date payments began and reason:
Are you currently using any Assistance Devices? yes    no
If yes, what device and how long?:
   
LTC Policy Benefit Options
Elimination Period*(days): 30   60   90   180   365
Inflation Coverage:* GPO (no charge) 
Simple 5% 
Compound 5%
Home Daily
Benefit Amount:*		 $
(Home Care Benefit is 100% of Nursing Home Benefit)
Benefit Period*(years): 3   4   5   6   10 
Unlimited
Riders:
   
delivery options
Deliver quote by:*
(choose preferred method)

e-mail:

phone:

fax:

Date quote needed:*
  *Red = Required Field