Long Term Care

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Broker Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Fax
Client Information
Client Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Risk Class
- Preferred
- Standard
- Rated
Height
Weight
Has applicant ever used tobacco?
- Yes
- No
Specify type & date of last use
Medications
Medical History
Spouse Name
First Last
Spouse Date of Birth
Date Format: MM slash DD slash YYYY
Spouse Risk Class
- Preferred
- Standard
- Rated
Height
Weight
Has applicant ever used tobacco?
- Yes
- No
Specify type & date of last use
Spouse Medications
Spouse Medical History
State of Residence
Benefit Amount
Is this benefit amount:
- Daily
- Monthly
Marital Status
- Married
- Single
Elimination Period (days)
- 30
- 60
- 90
- 180
- 365
Benefit Period (years)
Inflation
Home Care
- 50%
- 75%
- 100%
Non-Forfeiture Benefit
- Yes
- No
HHC Waiver?
- Yes
- No
Shared Care
- Yes
- No
Payment Options
Are you in competition for this case?
- Yes
- No
Additional Options
Comments

4820 Six Forks Rd. Raleigh, NC 27609
Phone: 919.981.0333

Client Information