LTC Quote Step 1 of 5 20% Agent InformationName* First Last Phone*Email* Resident State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingResident License Number* Client Personal InformationName* First Last Gender* Male Female Date of Birth* MM slash DD slash YYYY 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 Yes No Marital Status* Single Spouse/Partner not applying Spouse/Partner both applying Spouse/Partner Personal InformationName* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female State 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 tobacco Yes No Client Quote SelectionCarrier* Mutual of Omaha National Guardian Lite LTC OneAmerica (Hybrid) Thrivent RateClass* Preferred (Mutual of Omaha, National Guardian Select (Mutual of Omaha, National Gaurdian) Standard Class 1 (Substandard) (25% premium rate up Mutual of Omaha) Class 2 (Substandard) (50% premium rate up Mutual of Omaha) Daily/Monthly Benefit Amount $*Elimination Period* 30 60 90 180 365 Benefit Period* 2 years 3 years 4 years 5 years 6 years Lifetime (National Guardian Lite) Benefit Amount*Inflation Protection* None Simple Compound GPO (Guaranteed Purchase Option) HHC* 100% 75% 50% None Riders HHC 1st day waiver of EP Shared Care Waiver of Premium Joint 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* Preferred (Mutual of Omaha, TransAmerica, National Guardian) Select (Mutual of Omaha, TransAmerica, National Gaurdian) Standard Class 1 (Substandard) (25% premium rate up Mutual of Omaha & TransAmerica) Class 2 (Substandard) (25% premium rate up Mutual of Omaha & TransAmerica) Daily/Monthly Benefit Amount $*Elimination Period* 30 60 90 180 365 Benefit Period (Duration)* 2 years 3 years 4 years 5 years 6 years Lifetime (National Guardian Lite) Benefit Amount*Inflation Protection* None Simple (5%) Compound GPO Compund Inflation Protection 2% 3% 4% 5% HHC* 100% 75% 50% None Riders 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.Untitled First Choice Second Choice Third Choice
