LTC Quote Step 1 of 5 20% Agent InformationName* First Last Phone*Email* Client Personal InformationName* First Last Gender*MaleFemaleDate of Birth* State of Residence*Select A StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHas applicant used tobacco in any form in the last 5 years?*Tobacco use includes the following: Any cigarettes including vapor cigarettes Pipe smoking regardless of use Cigars including celebratory (include explanation in memo at the end of form) Snuff, chew or chewing tobacco YesNoMarital Status*SingleSpouse/Partner not applyingSpouse/Partner both applyingSpouse/Partner Personal InformationName* First Last Date of Birth* Gender*MaleFemaleState of Residence*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHas spouse/partner used tobacco in any form in the last 5 years?*Tobacco use includes the following: Any cigarettes including vapor cigarettes Pipe smoking regardless of use Cigars including celebratory (include explanation in memo at the end of form) Snuff, chew or chewing tobaccoYesNo Client Quote SelectionCarrier* Genworth Mutual of Omaha Transamerica RateClass*PreferredStandardClass 1 (Substandard)Class 2 (Substandard)Daily/Monthly Benefit Amount $*Elimination Period*306090180365Benefit Type*DurationPool of MoneyBenefit Period*2 years3 years4 years5 yearsBenefit Amount*Inflation Protection*NoneSimpleCompoundGPOHHC*100%75%50%NoneRiders HHC 1st day waiver of EP Return of Premium Restoration of Benefits Shared Care Waiver of Premium Non-Forfeiture * If Shared Care is selected spouse/partner benefit selections will be the same. You also have to select Spouse/Partner both applying under marital status on the client information page. Shared Care selected Spouse/Partner benefits will be the same as the primary applicants.Spouse/Partner Quote SelectionRisk Class*PreferredStandardClass 1 (Substandard)Class 2 (Substandard)Daily/Monthly Benefit Amount $*Elimination Period*306090180365Benefit Type*DurationPool of MoneyBenefit Period*2 years3 years4 years5 yearsBenefit Amount*Inflation Protection*NoneSimpleCompoundGPOHHC*100%75%50%NoneRiders HHC 1st day waiver of EP Return of Premium Restoration of Benefits Waiver of Premium Non-Forfeiture Date & Time Needed*Additional NotesAny additional information you feel necessary to create the quote.
