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Long Term Care Quote Request 

 Agent Information
 Agent Name:  
 Email:  
 Phone:  
 Fax:  
 Date/Time of Day Needed:  
 Client Information
Marriage Status  Married/Committed Partner Yes No
 Client Name:  
 DOB:   /    /    Age
 Risk Class:   Preferred Standard  Rated Smoker
 Medications:  
 Medical History:  
 Spouse Information
 Spouse Name:  
 Spouse DOB:    /  /   
 Spouse: Risk Class   Preferred Standard  Rated Smoker
 Spouse Medications:  
 Spouse Medical History:  
 Plan Information 
 State of Residence  
 Benefit Amount    Daily   Monthly
Elimination  Period - days  30 60 90 180 365
Benefit Period - years  2 3 4 5 7 Other
Inflation  None 3% Compound 5% Compound Other- Explain in comment box.                           

Home Care

Assisted Living
 50%   100%

 50%   100%
Riders   Non-Forfeiture Restoration of Benefit Share Care Return of Premium Survivorship 1st Day Coverage for Home Care Waiver of Premium Joint Waiver of Premium  
Carriers   Genworth   John Hancock   Mass Mutual   Mutual of Omaha   Transamerica    Lincoln    OneAmerica
 Additional Options  
 Comments