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Long Term Care Request Form

Agent/Broker Information

Agent Name
Phone Number
Email Address
Street Address

Applicant Information

Applicant Name
Marital Status
. Single. Married.. Domestic Partner
State of Residence
Date of Birth
......
Height / Weight
......

Client Health Information

Any Type of Cancers?
. YES.... NO
Heart Diseases?
. YES.... NO
Diabetes?
. YES.... NO
Arthritis?
. YES.... NO
Uncontrolled Blood Pressure?
. YES.... NO
A Stroke or TIA?
. YES.... NO
Smoker?
. YES.... NO

Explanation / Treatment / Date Occurred

Medications

Applicant Information

Applicant Name
Marital Status
. Single. Married.. Domestic Partner
State of Residence
Date of Birth
... ...
Height / Weight
... ...

Client Health Information

Any Type of Cancers?
. YES.... NO
Heart Diseases?
. YES.... NO
Diabetes?
. YES.... NO
Arthritis?
. YES.... NO
Uncontrolled Blood Pressure?
. YES.... NO
A Stroke or TIA?
. YES.... NO
Smoker?
. YES.... NO

Explanation / Treatment / Date Occurred

Medications

Plan Design / Benefit Selection (Available options may vary by carrier and State)

Premium Threshold
Monthly.....Annual..

“Premium clients can afford to pay” - With regard to affordability, the industry guideline
is that premiums should be no more than 7 percent of one’s income on average
Does client want to receive care at home
. YES.... NO
Benefit Amount
Daily.....Monthly..

(National average of semi private room in nursing home $ 183 per day)
Benefit Duration
Years...... Lifetime

(Lifetime coverage is very $$ - average paid claim is closer to 3 yrs)
Elimination Period
Days.....(Example 90 Days)
Inflation
. YES.... NO
Riders
..Home Care Elimination Period Waiver
(Most popular rider, client receive care day 1 at home)
..Shared Care
(Spouses can share each others policies)
Premium Payment Options
. Life Pay.... Limited Pay
Premium Mode
. Annual.... Semi Annual
. Quarterly.... Monthly

Riders / Comments / Special Requests

Send us the form

Download the Long Term Care Quote Request form as a PDF by clicking on the link below. Or simply fill out the web form on this pageand click submit.
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