Long Term Care Insurance Proposal Request

Long Term Care Insurance Proposal Request Form

Submission Routing

Please provide your location information below:

Your City Name:

Your Zipcode:

Your Location (required):

Producer Information

Name:

Phone:

(please include your area code.)

Fax:

(please include your area code.)

Email (required):

All proposals and product information will be sent to you by email unless we are instructed otherwise.

Client Information 1:

Name:

Birth Date:

Gender:
MaleFemale

State of Residence:

Residential Status

Tobacco or Nicotine Use:
YesNo

Medical Information

Current Medications & Dosages

Medical History

Underwriting Class Requested
PreferredStandard

Other:

Current Height

Current Weight

Has this client applied for, been issued or been declined for LTCi in the past?
YesNo

Details:

Client Information 2:

Name:

Birth Date:

Gender:
MaleFemale

State of Residence:

Residential Status

Tobacco or Nicotine Use:
YesNo

Medical Information

Current Medications & Dosages

Medical History

Underwriting Class Requested
PreferredStandard

Other:

Current Height

Current Weight

Has this client applied for, been issued or been declined for LTCi in the past?
YesNo

Details:

Illustration:

Coverage Requested:
ReimbursementIndemnityCash

State of Policy Issue

Benefit Period
123456710Lifetime

Benefit Design
MonthlyDaily

Benefit Amount

Home Healthcare
0%50%75%100%

Elimination Period
0 Days20/30 Days50/60 Days90/100 Days180 Days365 Days

Inflation Riders
NoneCPISimpleCompound 3Compound 5

Additional Riders

Shared CareReturn of PremiumRestoration of BenefitsWaiver of PremiumUninsurable SpouseSurvivorshipZero Day EP for Home CareOther

Regular Payment Modes:
AnnualSemi-AnnualQuarterlyMonthly

Limited Payment Plans:

10 Day Premium20 Day PremiumPaid up at age 65

Is this a partnership case?
YesNo

Special Instructions:

Carrier Selection

Would you like your local Plus Group Office to suggest the one carrier we feel provides the best value for your client?
YesNo
(If you select NO, multiple quotes will be provided)

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THE PLUS GROUPS DISABILITY INSURANCE REQUEST FORM

Don’t hesitate to contact your local Plus Group office for more information on how an affiliation will benefit your practice and your clients.