Agent Info:

    Name:      

    Agency:     

    Address:    

    City:               State:      Zip:      

    Phone #:         Fax #:

    e-mail address: 

General Information:

    Clients Name:     DOB:  

    Sex:   Male Female      Issue state:      Smoker:   Yes No

    Class:  Preferred    Select     Standard    Rated     

    Qualified         Non-qualified      

    Company:  State Life Unim CNA Allianze Fortis AIG

   Premium mode:   Annual Semi-annual Quartrtly Monthly W/D    Premium duration:    Lifetime 10 Payment Single Payment

Policy Information: 

Long Term Care:

    Reimbursement:            Indemnity:    

   Elimination Period:   0 7 14 20 30 90 60 100 120 180         Benefit Period:   Lifetime 6 year 5 year 4 year 3 year 2 year 1 year     

Nursing Home:  

    Daily Benefit:   See Monthly 20 30 40 50 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250         Monthly Benefit:   See Daily 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 4100 4200 4300 4400 4500 4600 4700 4800 4900 5000 5100 5200 5300 5400 5600 5700 5800 5900 6000 6100 6200 6300 6400 6500 6600 6700 6800 6900 7000 7100 7200 7300 7400 7500 7600 7700 7800 7900 8000   

Home Health Care:   Yes No

    (pick 1&2 or 3)

   1. Elimination Period:   N/A 0 7 14 20 30 90 60 100 120 180     2. Benefit Period:   N/A Lifetime 6 year 5 year 4 year 3 year 2 year 1 year  

    3. Home Health Care Policy Maximum:   N/A 100% 80% 60% 50%

   HCBC Health Care Waiver:   Yes No    HCBC Enhancement Rider:   Yes No   

Riders:

    Inflation Protection:   None CPI 5% Simple 5% Compounded   Indemnity Rider:   Yes No

    Non Forfeiture Feature:   Yes No    Survivorship Waiver:   Yes No

Health History:

    Health problems including medications: