LTC Quote Request Form
SECTION I: APPLICANT INFORMATION
Applicant's Name:
Applicant's Date of Birth:
Applicant's Sex: Male
Female
Has the applicant used tobacco in the last 12 months? Yes
No
Quote a preferred class on the applicant? Yes
No
SECTION II: Joint Client Information
Joint applicant's name:
Joint applicant's Date of Birth:
Joint applicant's Sex: Male
Female
Has the joint applicant used tobacco in the last 12 months? Yes
No
Quote a preferred class on the joint applicant? Yes
No
SECTION III: Quote Information
State of quote:
Company(s) requested:
Daily benefit: Monthly
Elimination Period:
Benefit period:
Inflation:
HHC amount: 0%
50%
75%
100%
HHC indemnity? Yes
No
HHC waiver of Elimination Period? Yes
No
Payment options Annual
Semi-Annual
Quarterly
Monthly
Pre-payment options 10 Pay
Single Pay
Pay to 65
Return of premium:
SECTION IV: Case Information
Are you in competition for this case? Yes
No
I don't know
If yes, please specify
Additional comments or health concerns?