Long Term Care Quote Step 1 of 5 - Agent Information0%Name* First Last TitleBusiness NameUse address of record YesMailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneFax NumberEmail* Name #1 First Last Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexMaleFemaleSexMaleFemaleTobacco UserYesNoIf Yes, Describe UsageGeneral Health / Existing ConditionsName #2 First Last Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexMaleFemaleTobacco UserYesNoIf Yes, Describe UsageGeneral Health / Existing ConditionsState & Zip Code of ResidencyIncome During RetirementApproximate AssetsTypePartnershipNon-PartnershipPartnershipNew YorkConnecticutOtherIf other indicate what stateElimination Period0 Days20 Days30 Days45 Days60 Days90 Days100 Days180 Days365 DaysPolicy Max Benefit2 Years3 Years5 Years7 YearsUnlimitedNursing HomeHome Health Care50%60%75%80%100%Inflation Option5% Compound5% SimpleCPINoneBenefit OptionDailyMonthlyCashLimited Pay Option10 PayReduced Pay at Age 65Paid Up at Age 65Additional Riders Non-Forfeiture Shared Benefits Restoration of Benefits Dual Waiver of Premium SurvivorshipNOTE - elimination periods, benefit periods, and daily benefit options may vary by company. NOT all companies have all riders available.Additional Information / Special Instructions / Goal We Would Like To MeetThis Illustration Is Needed ByMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I Would Like My Request Sent By E-mail Fax Mail