WS LTC/Life Hybrid Step 1 of 4 25% Agent InformationName* First Last Phone*Email* Resident State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingResident Insurance License Number* Client Personal InformationName* First Last Gender*MaleFemaleDate of Birth* Date Format: 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 YesNoMarital Status*SingleSpouse/Partner not applyingSpouse/Partner both applyingSpouse/Partner Personal InformationName* First Last Date of Birth* Date Format: MM slash DD slash YYYY 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* One America (LTC/Life Hybrid) RateClass*Non Tobacco - PreferredSmoker - StandardBenefit Period*50 months33 months25 monthsInput Method*Premium AmountFace AmountInitial Monthly LTC BenefitMonthly Benefit Amount Desired*Please enter a number greater than or equal to 0.Premium AmountFace AmountElimination (Preset by carrier)* Home Health Care - 0 days All other LTC Services - 90 days Inflation Protection - Base plan (if available)*NoneCompund (3%)Compound (5%)Inflation Duration20 YearsLifetimeInflation Protection (Continuation Benefit Rider)*None3%5%Waiver of Premium Rider*Automatically IncludedYesNo Date & Time Needed*Additional NotesAny additional information you feel necessary to create the quote.