Long Term Care (LTC) Quote Proposal Form:
Fields marked with * are required
Tab through the questions, do NOT hit enter till completed.
Customer Name (required):
First MI Last
Email (required) :
Date of Birth:
/ /
Sex:
Height & Weight:
&
Tobacco Use:
Never No Yes
Marital Status :
State of Primary Residence :
Daily Nursing Home Benefit desired :
$
Benefit Period :
 
Rate Class :
Waiting Period Before Benefits Begin :
Include Compound Inflation Protection?:
Yes (recommended) No
Include Home Health Care Coverage?:
 Yes No
Include Spouse Discount? :
Yes No (Spouse discount applies for most companies when both husband and wife apply for coverage at the same time)
Optional Spouse Information
Name : First MI Last
Date of Birth:
/ /
Height & Weight:
&