Name:                     D.O.B. 
Height:     Weight:      Do you use tobacco?  YES NO
 
Spouse:                  D.O.B. 
Height:     Weight:      Do you use tobacco?  YES NO

 
Address:  
City:           State:   Zip: 
Phone:      E-Mail: 

Do you currently have a long term care policy? YES NO

If yes, with which company?
If yes, what is the major reason for your inquiry into another quote?

Nursing Home Benefit

$100 $110 $120 $130 $140 $150 $160 $170 $180 $190 $200 $210 $220 $230 $240 $250 Amount per day

2 Years 3 Years 4 Years 5 Years Unlimited Benefit Period

Home Health Care Benefit

$100 $110 $120 $130 $140 $150 $160 $170 $180 $190 $200 $210 $220 $230 $240 $250 Amount per day

2 Years 3 Years 4 Years 5 Years Unlimited Benefit Period

Elimination Period

0 days 30 days 60 days 90 days 180 days

Mode of premium payment Lifetime - Ongoing Single Pay - Lump Sum Ten Years Five Years or to Age 65 Monthly Semi-annually Quarterly Annually

List any major health conditions, if any that you and/or your spouse have or have had in the past 5 years.

List any medications that you and/or your spouse are currently using.

Any comments or suggestions?