Agents: Get an insurance quote for a client Agent Name* First Last Phone*Email* FaxAppointment Date/Time Type of Quote You Are Requesting:*Long-Term CareCareShield ULCritical 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*The CareShield product with Minnesota Life/Securian uses AGE NEAREST. If available, please also include client's Date of Birth. Client HeightClient Weight: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 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 Genworth 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 Informal Care Benefit Elimination Period Credit Rider Full Restoration of Benefits 10-Pay 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) Face Amount$50,000 - $500,000 (in $1 Increments) Remember, the Chronic Illness Benefit is automatically 4% of the selected Face Amount.Choose 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 DisabilityClient Occupation DetailsPlease provide details on the client's occupation, including job title and a description of typical daily responsibilities.Plan 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:
