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Long Term Care Proposal

Submitted by administrator on Thu, 10/22/2009 - 14:26
 Submission Routing
 
Your Location:  
 
 Producer Information
  
Name:
Phone:
(area) (xxx-xxxx)
Fax:
(area) (xxx-xxxx)
Email:

All proposals and product information will be sent to you by email unless we are instructed otherwise.

 
 Client 1 Information:
 
Name:
Birth Date: / /
(mm/dd/yyyy)
Gender: Male Female
Residential Status: Married Single Partner Shared Residence
State of Residence:
Tobacco or Nicotine Use: Yes No
 
Medical Information
 
Medications and Dosages:
Medical History:
Underwriting Class Requested Preferred Standard
Other
Height:
Weight:
Has this client applied for, been issued or been declined for LTCi in the past? Yes No
Details:
 Client 2 Information:
 
Name:
Birth Date: / /
(mm/dd/yyyy)
Gender: Male Female
Residential Status: Married Single Partner Shared Residence
State of Residence:
Tobacco Use: Yes No
 
Medical Information
 
Medications and Dosages:
Medical History:
Underwriting Class Requested Preferred Standard
Other
Height:
Weight:
Has this client applied for, been issued or been declined for LTCi in the past? Yes No
Details:
 
 Illustration:
 
Coverage Requested: Reimbursement Indemnity Cash
State of Policy Issue:
Benefit Period: 1 2 3 4 5 6 7 10 Lifetime
Benefit Design: Monthly Daily
Benefit Amount:
Home Healthcare: 0% 50% 75% 100%
Elimination Period: 0 Days 20/30 Days 50/60 Days 90/100 Days 180 Days 365 Days
Inflation Riders: None CPI Simple Compound 3 Compound 5
Additional Riders:
Shared Care
Return of Premium
Restoration of Benefits
Waiver of Premium
Uninsurable Spouse
Survivorship
Zero Day EP for Home Care
Other
Regular Payment Modes: Annual Semi-Annual Quarterly Monthly
Limited Payment Plans:
10 Pay Premium
20 Pay Premium
Paid up at age 65
Is this a partnership case?: Yes No
Special Instructions:
 
Carrier Selection
 
Would you like your local Plus Group Office to suggest the one carrier we feel provides the best value for your client? Yes No

(If you select NO, multiple quotes will be provided)

 
An Illustration cannot be provided unless this form is completely filled out.