Long Term Care Quote Request Form:

* Broker Name:

* Address:

* City:   * State:   * Zipcode:

* Phone Number:   Cell Phone:   Fax Number:

* Best Times To Call:  

* E-mail Address:

* Indicates Required Fields

Return Method:     Fax   Mail   Broker Pick-up   E-mail

Insurance Company Preference, If any:

Plan:   State:

Client:

* Name:

* Birth Year (Example: 1928):   * Gender: Male   Female

Rate Class: Preferred   Standard

Daily Benefit Amount:     Home Care: 50%   75%   100%

Benefit Period:   2 years   4 years   Lifetime   or Other Period :

Elimination Period (days):  0   30   90   Other:

Inflation Protection:  Simple   Compound   Cost of Living Incease

Spouse:

Name:

* Birth Year:     Gender: Male   Female

Rate Class: Preferred   Standard

Duplicate Benefits From Above: Yes  No

If No, Please complete the Following:

Daily Benefit Amount:     Home Care: 50%   75%   100%

Benefit Period:   2 years   4 years   Lifetime   or Other Period:

Elimination Period (days):  0   30   90   Other:

Inflation Protection:   Simple   Compound   Cost of Living Increase

Pre-Underwriting:

Please list any additional comments, and any significant health conditions,
associated medications AND/OR hospitalizations in the last 5 years.