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.

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