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Long Term Care Insurance Quote

General Information

Name: Address: City:  State:  ZIP: County:   Twp or Borough: Phone Day: -           Night: - Best time to call:  am  pm E-mail:        Fax: - Occupation:        How long at current job: years months Spouses Occupation:        How long at current job: years months How would you like to be contacted? Telephone E-mail Fax

About Yourself:

Sex Marital Status Date of Birth Height Weight M F S M -- ft in lbs If spouse also applying: -- ft in lbs In 10 years: Have you had any of the following health conditions: None of the Folllowing Cancer Severe Arthritis Alzheimer's Disease Multiple Sclerosis ALS,Lou Gehrig's Disease Parkinson's Disease Alcoholism Dementia Neurogenic Bladder Myasthenia Gravis AIDS/HIV Has your spouse had any of the following health conditions: None of the Folllowing Cancer Severe Arthritis Alzheimer's Disease Multiple Sclerosis ALS,Lou Gehrig's Disease Parkinson's Disease Alcoholism Dementia Neurogenic Bladder Myasthenia Gravis AIDS/HIV Are you or your spouse currently on any prescription medications for ongoing health conditions? Yes No    If yes, please list: Please DISCLOSE any and all health conditions you or your spouse have (or had in the past 10 years):

Please select the following coverages:

Long Term Care Coverages Daily Benefit $50 $100 $110 $120 $130 $140 $150 $160 $170 $180 $190 $200 Minimum Years of Coverage 2 years 3 years 4 years 5 years Unlimited Percentage of Daily Benefit for Home and Community Based Care 50% 100% Elimination Period 0 days 30 days 90 days 180 days 365 days Inflation Protection Coumpound Simple Not selected Non-forfeiture (After 3 years, if you no longer pay the premium, the benefits will be payable for covered long term care up to the amount of premium you have paid or 30 times the daily benefit, whichever is greater. Selected Not Selected Are you interested in information for annuities/retirement planning? yes no Are you interested in information on life insurance? yes no

Additional Comments:

Please give any additional comments you desire: