How may we contact you? (remember to specify this contact information above)
Home Phone
Work Phone
FAX
E-mail

CLIENT INFORMATION
Client Name:		Joint Applicant Name: (i.e. Spouse)
Client Birthdate (DOB):		Joint Applicant DOB:

Please complete as much of the following as you can at this time. Thank you.
If you are unsure about an option, simply leave it unselected. (Leave it as "Select One")

Facility Care Daily Benefit Amount: Select One $50.00 $60.00 $70.00 $80.00 $90.00 $100.00 $110.00 $120.00 $130.00 $140.00 $150.00 $160.00 $170.00 $180.00 $190.00 $200.00
Facility Care Daily Benefit Amount represents the daily amount of coverage reimbursed by the insurance company for facility care. This would include nursing homes, assisted living facilities, residential care facilities and adult congregate care.

Benefit Period: Select One 2 Years 3 Years 4 Years 5 Years Life
Benefit Period represents the number of years benefits will be paid from 2 years to life (unlimited).

Elimination Period: Select One 0 Days 30 Days 60 Days 90 Days 180 Days
Elimination Period is like a deductible and represents the number of days at the beginning of the covered stay before the benefit payments actually begin. (The longer the elimination period, the lower the premium.)

Home Care Daily Benefit: Select One 0% 50% 100%
Home Care Daily Benefit represents 0%, 50%, or 100% of the Facility Care Daily Benefit for Home Care Benefits. These benefits include skilled home health care providers, adult day care, homemaker, hospice, and personal care services.

Cost of Living Adjustment (COLA): Select One None 5% Simple 5% Compound
Cost of Living Adjustment (COLA) increases both facility and home health care benefits to keep pace with the rising cost of care.

Does your client smoke? Yes No

Does your client's joint applicant smoke (i.e. spouse)? (leave unselected if this does not apply)
Yes No

Please specify answers for each applicant in the following questions.

Health Condition: Please describe client's overall health condition here. No physical examination is required for Long Term Care insurance. Your client need only answer a few simple questions.

Hospitalizations: Please describe client's hospitalizations in the last 10 years.
[i.e. Reason, how long ago, results (i.e full recovery)]

Medications: Please list any medications your client is currently taking.
[i.e. Name of medication, amount taken daily, how long they've been taking it, reason they're taking it]

Special Requests or Questions about Long Term Care:

You may SUBMIT this Long Term Care Insurance Quote Request when you are finished or CLEAR this form to start again.