Agents: Get an insurance quote for a client Agent Name* First Last Phone*Email* FaxAppointment Date/Time Date Format: MM slash DD slash YYYY Type of Quote You Are Requesting:*Long-Term CareSecureCareCritical Cash™DisabilityClient's Resident State:*Does your client have a spouse/partner?*YesNoSpouse/Partner also applying?YesNoClient Name* First Last Client Gender:*MaleFemaleDoes Client use tobacco?*YesNoClient Date of BirthClient Age*Client HeightClient Weight:Client Occupation Details*Please provide details on the Client's occupation, including job title and a description of typical daily responsibilities.Client Annual Gross Income:*Client Health History for last 5 years:Client medications including dosage and length of treatment:Spouse/Partner Name First Last Spouse/Partner Gender:*MaleFemaleDoes Spouse/Partner use tobacco?*YesNoSpouse/Partner Date of BirthSpouse/Partner Age*Spouse/Partner HeightSpouse/Partner Weight:Spouse/Partner Occupation Details*Please provide details on the Spouse/Partner's occupation, including job title and a description of typical daily responsibilities.Spouse/Partner Annual Gross Income:*Spouse/Partner Health History for last 5 years:Spouse/Partner medications including dosage and length of treatment:*Design A Plan:Within Client's BudgetWith Following Benefits & OptionsDesign A Plan Within The Following Budget:Design A Plan Within Client's Budget, For:Self & Spouse/PartnerSelf OnlyDesign A Plan With The Following Carriers:Benefit availability may vary with carriers. We will create as comparable of plans as possible, through the carrier(s) selected below. Mutual of Omaha Transamerica National Guardian Life ("NGL") United Security Assurance Maximum Monthly Benefit$1,500 - $10,000 (in $50 Increments)Policy Limit And/Or Plan Length$50,000 - $500,000 (in $500 Increments) OR 1 year - 8-year, or Lifetime (NGL only)Compound Inflation1% - 5% (in 0.25% Increments)Compound Buy-Up Options / Inflation TermLifetime10 Year15 Year20 YearElimination Period0 day30 day40 day60 day90 day120 day180 day365 dayWaive Elimination Period for Home Health Care?YesNoAssisted Living (Percentage of Maximum Monthly Benefit)100%75%50%Home Health Care (Percentage of Maximum Monthly Benefit)100%75%50%Select Optional Riders:Certain rider combinations may not be valid. Availability may vary depending on carrier. Monthly Benefits (vs Daily) Calendar-Day Elimination (vs Service-Day) Non-Forfeiture 200% Professional HHC Benefit Return of Premium Death Benefit (Less Claims) Waiver of Premium Elimination Period Credit Rider Full Restoration of Benefits 10-Pay (NGL Only) Single-Pay (NGL Only) Select Optional Couples Riders:Certain rider combinations may not be valid. Availability may vary depending on carrier. Shared Care Joint Waiver of Premium Survivorship Security Benefit (Benefits for Uninsurable Partner) SecureCare Plan Design:Select how you wish the plan to be built.Specify Monthly LTC Benefit AmountSpecify Premium AmountSpecify Face AmountSpecify Monthly LTC Benefit Amount:Specify Premium AmountSpecify Face AmountOptions range from $50,000 - $500,000SecureCare Premium Payment Options:For multi-year policies, all premium modes available (Annual, Semi-Annual, Quarterly, Monthly EFT). Single Pay (available for ages 40-75) 5-Pay (available for ages 40-70) 7-Pay (available for ages 40-68) 10-Pay (available for ages 40-65) 15-Pay (available for ages 40-60) Long-Term Care Benefit Duration: 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years Long-Term Care Inflation Protection Agreement:This agreement provides an increase in the long-term care benefit payments each year to help offset the rising cost of services. No Inflation 3% Simple 3% Compound 5% Simple 5% Compound 1035 Exchange:YesNo1035 exchange is used as premium in first year. Annualized premium must be greater than or equal to the 1035 amount.External 1035 amount:Total 1035 basis:1035 amount from MEC:YesNoChoose Your Plan: Plan AConditions for which diagnosis would trigger benefits: Cancer, Cancer In-Situ, Heart Attack, Coronary Artery Bypass Surgery, Stroke, Alzheimer’s Disease, Kidney Failure, Major Organ Transplan, Paralysis, Coma Applicant Spouse Choose Your Plan: Plan BConditions for which diagnosis would trigger benefits: Same as Plan A, EXCEPT: Heart Attack, Coronary Artery Bypass Surgery, Stroke Applicant Spouse Choose Your Plan: Plan CConditions for which diagnosis would trigger benefits: Same as Plan A, EXCEPT: Cancer, Cancer In-Situ Applicant Spouse Benefit Period: 6 Months 12 Months 18 Months 24 Months Monthly Base Benefit: $500 $750 $1,000 $1,250 $1,500 $1,750 $2,000 $2,250 $2,500 $2,750 $3,000 $3,250 $3,500 $3,750 $4,000 $4,250 $4,500 $4,750 $5,000 $5,250 $5,500 Nursing Home Monthly Benefit:Monthly benefits for Assisted Living are equal to 50% of the selected Nursing Home Monthly Benefit. * Total Monthly Benefits may not exceed $6,000: i.e. If Monthly Base Benefit is $2,000, Nursing Home Monthly Benefit may not exceed $4,000. $500 $750 $1,000 $1,250 $1,500 $1,750 $2,000 $2,250 $2,500 $2,750 $3,000 $3,250 $3,500 $3,750 $4,000 $4,250 $4,500 $4,750 $5,000 $5,250 $5,500 Return of Premium:* Return of Premium may not be available in all states. Yes No Type of Disability Insurance:Short-Term DisabilityLong-Term DisabilityPlan Length (Months) 3 months 6 months 12 months 24 months Elimination Period Length (Days) 0/7 0/14 7/7 14 30 60 90 Critical Illness Benefit Option Amount($5,000, $10,000, $15,000, or $20,000)DI Hospital Confinement Indemnity BenefitDaily Room & Board Benefit Amount ($125, $250, $350, $500)Return of Premium 50% 80% Accidental Medical Expense Rider Benefit Amount($1,000, $2,000, $3,000, $5,000)Plan Length (Years) 2 years 5 years 10 years To Age 67 Elimination Period Length (Days) 60 90 180 365 Cost of Living Adjustment Rider$1,500 - $10,000 ($50 Increments)Extended Own-Occ Disability$50,000 - $500,000 ($500 Increments)Extended Proportionate Rider$1,500 - $10,000 ($50 Increments)Future Insurability Option$50,000 - $500,000 ($500 Increments)Critical Illness Benefit Amount $($5k $10k $15k or $20k)DI Hospital Confinement Indemnity BenefitDaily Room & Board Benefit Amount ($125, $250, $350, $500)Return of Premium 50% 80% Accidental Medical Expense Rider Benefit Amount($1,000, $2,000, $3,000, $5,000)Design A Plan Within Client’s BudgetClient can spend up to $Comments:
