Home
Products
Product Information
Underwriting Guides
Quotes
Life Quotes
Quote Request
iGO/E-APP
Carrier Drop Tickets
Forms
Additional Forms
Contracting
My Cases
Contact Us
Home
Products
Product Information
Underwriting Guides
Quotes
Life Quotes
Quote Request
iGO/E-APP
Carrier Drop Tickets
Forms
Additional Forms
Contracting
My Cases
Contact Us
Long Term Care Insurance Proposal Request
Agent Information
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Fax Number
*
Insured Information
Client #1
Client Initials
*
Date of Birth
*
Height
*
Weight
*
Significant Medical History & Medications (Dates & Dosages)
*
Cane, Walker or Wheelchair?
*
Yes
No
Tobacco use Last 12 months
*
Yes
No
Indicate if you have been medically diagnosed or treated for any of the conditions below:
Heart or Circulatory Disorder
*
Yes
No
Chronic Respiratory Disorder
*
Yes
No
Receiving Physical Therapy
*
Yes
No
Scheduled Treatment or Surgery
*
Yes
No
Abnormal Blood Pressure
*
Yes
No
Bladder or Bowel Control
*
Yes
No
Falling or Unstable Gait
*
Yes
No
Dizziness or Fainting
*
Yes
No
Confusion or Memory Loss
*
Yes
No
Weakness or Fatigue
*
Yes
No
Neurological Disorder
*
Yes
No
Diabetes
*
Yes
No
Cancer
*
Yes
No
Stroke or TIA
*
Yes
No
Client #2
Client Initials
*
Date of Birth
*
Height
*
Weight
*
Significant Medical History & Medications (Dates & Dosages)
*
Cane, Walker or Wheelchair?
*
Yes
No
Tobacco Use Last 12 Months?
*
Yes
No
Indicate if you have been medically diagnosed or treated for any of the conditions below:
Heart or Circulatory Disorder
*
Yes
No
Chronic Respiratory Disorder
*
Yes
No
Receiving Physical Therapy
*
Yes
No
Scheduled Treatment or Surgery
*
Yes
No
Abnormal Blood Pressure
*
Yes
No
Falling or Unstable Gait
*
Yes
No
Bladder or Bowel Control
*
Yes
No
Dizziness or Fainting
*
Yes
No
Confusion or Memory Loss
*
Yes
No
Weakness or Fatigue
*
Yes
No
Neurological Disorder
*
Yes
No
Diabetes
*
Yes
No
Cancer
*
Yes
No
Stroke or TIA
*
Yes
No
Requested Benefit Design
Daily Benefit Amount $
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Washington D.C.
West Virginia
Wisconsin
Wyoming
Elimination Period
*
30 days
60 days
90 days
Other
Inflation Protection
*
5% Simple
5% Compound
Other
Benefit Period Number of Years
*
Choose Any
*
Traditional LTCi
Partnership
Couples Only - Shared Care
*
Yes
No
Payment Option Annual
*
Monthly
Quarterly
Semi-Annual
Annual
Submit