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LONG TERM CARE QUOTE REQUEST

Please fill in as much information as possible, as it will help us serve you more effectively.

 

Applicant Information

Name (required)

Mailing Address

City

State

Zip Code
 

Physical Address

City

State

Zip Code

Phone

Fax

E-Mail (required)

Applicant Personal Information

Date of Birth

Height

Weight

List any conditions and medications (include dosage)

1.

2.

3.

4.

Spouse Personal Information

Date of Birth

Height

Weight

List any conditions and medications (include dosage)

1.

2.

3.

4.

 

  YOU SPOUSE
Currently in a nursing home or receiving home health care? Yes No Yes No
Currently on disability? Yes No Yes No
Have surgery scheduled? Yes No Yes No
Have any physical limitations? Yes No Yes No
Frequent or recent hospitalization? Yes No Yes No
Any physical limitations? Yes No Yes No
Tobacco use? Yes No Yes No
High blood pressure? Yes No Yes No
Diabetes? Yes No Yes No

CURRENTLY USING... YOU SPOUSE
Oxygen Yes No Yes No
Wheelchair Yes No Yes No
Crutches Yes No Yes No
Cane Yes No Yes No


Policy Outline

Employment Status

Individual  S Corporation  C Corporation  Partnership  Sole Proprietor

Premium Payment

Individual  Corporation

Daily Benefit
$

Benefit Period

2 yr  3 yr 5 yr Lifetime

Elimination Period

30 days  60 days 90 days 180 days

Automatic Benefit Increase

None  Simple Compound

Accelerated Payment Option

Lifetime  10 payments To age 65

Carrier Selection

MetLife Genworth John Hancock

      Mutual of Omaha Prudential

 

Comments

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Updated November 25, 2008 © 2008 Paolino Insurance Agency, Inc. legal notice