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	Life Insurance

Long Term Care Request

Fields marked with an asterisk (*) are required.

Return Method:
	Fax Mail E-mail

*Insurance Company Preference:


*Client's State of Residence:


State where application is to be signed:

Client:

Name:


*Birthdate (or age):


*Sex:
	Male Female

*Client's Health Condition - Please list client's health conditions and medications or additional comments related to this case:

Daily or Monthly benefit amount:
	$

Choose One:
Home Health Care:
	50% 75% 100%

Benefit Period:
	2 years 3 years 4 years 5 years 6 years 10 years Lifetime

Elimination Period (days):
	0 30 60 90 180 365

Inflation:
	Simple Compound Guaranteed Purchase Option

Limited Pay Options:
	10-Pay Paid up to 65

Riders:
	Restoration of Benefits Return of Premium

Please list any budget considerations or competitive situations:

Spouse:

Name:


Birthdate (or age):


Sex:
	Male Female

Please list client's health conditions and medications or additional comments related to this case:


Duplicate Benefits From Above?
	Yes No (If no, complete the following)

Daily or Monthly benefit amount:
	$

Choose One:
Home Health Care:
	50% 75% 100%

Benefit Period:
	2 years 3 years 4 years 5 years 6 years 10 years Unlimited Benefit

Elimination Period (days):
	0 30 60 90 180 365

Inflation:
	Simple Compound Guaranteed Purchase Option

Limited Pay Options:
	10-Pay Paid up to 65

Riders:
	Restoration of Benefits Return of Premium

Questions? Call (800) 837-5433