Long Term Care Quote Request Advisor Information Advisor Name *required Address City, State, Zip Code Email Address *required Business Phone *required Cell Phone Fax Health Licensed in state of: Long-Term Care training/education expires: Client Information (Please complete and submit a separate quote request for spouse, family member or partner) Provide quoting companion's name: Relationship to applicant: Applicant's Name Date of Birth Gender Male Female Resident State If ever filed for bankruptcy, provide date(s): Previously declined for LTC insurance? Yes No Currently receiving disability benefits? Yes No If yes, provide type/reason: Tobacco/Nicotine Use Yes No Type used How often used Date last used Current Height and Weight Weight Change Yes No Reason for weight change List all current medications and reason for taking List details for personal health conditions in the past 5 years (back or neck injuries, diabetes, sleep disorders, hypertension, cancer, drug or alcohol abuse) In the past 5 years, have you used a cane/walker, crutches, wheelchair? If yes, provide details. Do you have a Handicap Parking Permit? Yes No In the past 5 years, has applicant had any of the following: Hospitalizations, Heart Disease, Physical Therapy, Carotid Artery Disease, Transient Ischemia Attack, Peripheral Vascular Disease, Stroke/CVA, Blood Clots/Embolism, Alzheimer’s/Dementia, Depression/Mental Illness, Memory Loss/Forgetful, Chronic Fatigue/Fibromyalgia, Kidney Disease, Crohn’s/Colitis/Gastric, Bypass, Liver Disorders, Back/Spine Disorders, Arthritis, Osteoporosis/Fractures, Seizure Disorders, Visual Impairments/Loss? Yes No If yes, please provide details to condition above. Provide any additional Medical/Health information for context and/or not listed above: Case Design Information Traditional LTC LTC/CI Life Hybrid If selected LTC/CI Life Hybrid Life Provide Death Benefit Specify LTC Benefit Amount or type MAX: Daily or Monthly Home Care Percent of Home Care Elimination Period Requested: Benefit Period Requested: Options Requested: Partial/Residual Cost of Living Future Purchase Rider Retirement Plan Deferral Automatic Increase Provide amounts for Future Purchase, Retirement Plan Deferral and Automatic Increase: Other Requests (include riders, premium paying years, etc): If you are human, leave this field blank.