Skip to content
Menu
About Us
Our Motto
Contact Us
Life
Our Life Carriers
Life Needs Calculator
Doc C’s Life Quoter
Doc C’s Easy App
Life Quote Request
DI / CI
Standard DocFast
Our DI/CI Carriers
DI Educational Tools
DI Quote Request
DI/CI Articles & Links
Plus Group Of Arizona
LTCi
Our LTCi Carriers
LTCi Quote Request
LTCi Articles & Links
NAIC LTC CE
Health
Our Health Carriers
Health Business Online
Annuity
Our Annuity Carriers
Annuity Quote Request
Broker Resources
Business Online
Training & Sales Ideas
Impaired Risk Questionnaires
Industry Links
E&O Insurance
AML Training
Broker World Magazine
Login
Register
Home
Contact
Close Menu
LTC request
Producer Information
Agent Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Phone
*
Fax
Client Information
Client Name
First
Last
Date of Birth
*
MM slash DD slash YYYY
Risk Class
Preferred
Standard
Rated
Height
Weight
Has applicant ever used tobacco?
Yes
No
Specify type & date of last use
Medications
Medical History
Spouse Name
First
Last
Spouse Date of Birth
MM slash DD slash YYYY
Spouse Risk Class
Preferred
Standard
Rated
Height
Weight
Has applicant ever used tobacco?
Yes
No
Specify type & date of last use
Spouse Medications
Spouse Medical History
State of Residence
*
Select A State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Benefit Amount
*
Is this benefit amount:
Daily
Monthly
Marital Status
*
Married
Significant Other
Both Applying
Single
Elimination Period (days)
*
30
60
90
180
365
Benefit Period (years)
*
Select One
2
3
4
5
6
Lifetime
Inflation
*
Select One
None
3% Compound
5% Compound
Other (Please Note Below)
Home Care
50%
75%
100%
Non-Forfeiture Benefit
Yes
No
HHC Waiver?
Yes
No
Shared Care
Yes
No
Payment Options
Select One
Annual
Semi-Annual
Quarterly
Monthly
Payment Duration
*
Lifetime
10-Pay
Single Premium
Are you in competition for this case?
Yes
No
Additional Options
Comments
Δ