LTC request

Producer Information
Agent Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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*
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)*
Inflation*
Home Care
- 50%
- 75%
- 100%
Non-Forfeiture Benefit
- Yes
- No
HHC Waiver?
- Yes
- No
Shared Care
- Yes
- No
Payment Options
Payment Duration*
- Lifetime
- 10-Pay
- Single Premium
Are you in competition for this case?
- Yes
- No
Additional Options
Comments

Δ

3821 E. Indian School Rd
Phoenix, AZ 85018
Phone: (800) 999-4773
or (602) 955-4773
Fax: (602) 956-3242
Email Us!

Producer Information