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Long Term Care Request Form


Date of Birth (MM/DD/YYYY):

Gender: Male   Female


State:    Zip Code:

Smoker: Yes   No

Spouse's Name:

Date of Birth (MM/DD/YYYY):

Smoker: Yes   No

Basic Policy:

Daily Benefit Amount ($20 to $300, in $10 increments):
Benefit Period: 3 Year   5 Year   Lifetime
Elimination Period: 0 Day   30 Day   90 Day
Home & Community Based Care (HCBC): Yes   No

Optional Benefits And Riders:

5% Compound Benefit Increase   5% Simple Benefit Increase

Indemnity Rider

Nonforfeiture Riders: Full Nonforfeiture   Shortened Benefit Period Nonforfeiture

List any medications that you (or your spouse) take on a regular basis. This will help to determine the initial proposed rates (Rate Class):


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