LTC Quotes

 Broker Information
 Broker *  
 Email *  
 Phone *  
 Fax  
 Date/Time of Day Needed  
 Client Information
 Client Name  
 DOB   /    /  
 Risk Class   Preferred Standard  Rated
 Medications  
 Medical History  
 
 Spouse Name  
 Spouse DOB    /  /   
 Spouse Risk Class   Preferred Standard  Rated
 Spouse Medications  
 Spouse Medical History  
 Plan Information 
 State of Residence  
 Benefit Amount    Daily   Monthly
Elimination  Period - days  30 60 90 180 365
Benefit Period - years  2 3 4 5 10 Lifetime
Inflation  None 5% Simple 3% Compound5% CompoundFPO
Home Care  50%   100%
Riders   Share Care  Refund of Premium  Restoration  Non-Forfeiture
 Survivorship, 7 year   Survivorship, 10 year 
Carriers   American General   Genworth   John Hancock   Mutual of Omaha
 Additional Options  
 Comments