Name (First, Middle, Last) 

Address 

City 

State 

Zip Code 

Birth Date 

Contact Phone Number 

email Address 

For Spouse Coverage 

Name (First, Middle, Last) 

Contact Phone Number 

Birthdate 

Do you (or spouse) have or have you applied for Long Term Care Insurance? yes no 

Have you (or spouse) ever been declined for Long Term Care or Health Insurance? yes no   

If yes, please explain:

The following information is needed to determine your possible rating classification: 

Height / Weight: You Spouse 

Do you take any medications on a regular basis? yes no    

If so, name,  dosage, frequency, reason, MD.

You

Spouse 

Have you required medical treatment or hospitalization within the past 5 years?  yes no

If yes, please give details. 

You

Spouse 

The following will help us determine if Long Term Care Insurance is appropriate for you: 

Do you have $75,000 or more in assets? yes no

Is your annual income $30,000 or more? yes no

The following questions form the basis of your plan of coverage: 

(For spousal coverage, do you want to duplicate the same plan design? If not, please indicate difference in comment section at the bottom) 

DESIGN OF YOUR LONG TERM CARE POLICY 

Your Name:

When would you like benefits to begin 20 30 60 90 100 180 (20, 30, 60, 90, 100, 180 days) 

Daily Benefit Amount  ($50 to $500) 

Home Health Care  50% 75% 80% 100% (50%, 75%,  80% or 100%  of Nursing Home)

How long do you want benefits to last 2 3 4 5 6 10 Life (2, 3, 4, 5, 6 10 years, or lifetime) 

Do you prefer: Indemnity or Reimbursement Plan 
(Indemnity pays you a flat daily benefit until the maximum benefit is paid, versus submitting bills for Reimbursement from a "pool of money" - payments can be made to you or the service provider) 

Optional Policy Riders: 

Inflation -

Compound Yes  No 

Simple Yes  No

Non-Forfeiture/Abbreviated Benefit Period Yes  No 

Paid-Up Survivor Benefit Yes  No

Abbreviated Premium Paying Period Yes  No 

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