Get a Quote - GoldenCare Agents

Agents: Get an insurance quote for a client

Agent Name*
First Last
Phone*
Email*
Fax
Appointment Date/Time
MM slash DD slash YYYY
Type of Quote You Are Requesting:*
Client's Resident State:*
Does your client have a spouse/partner?*
- Yes
- No
Spouse/Partner also applying?
- Yes
- No
Client Name*
First Last
Client Gender:*
- Male
- Female
Does Client use tobacco?*
- Yes
- No
Client Date of Birth
Client Age*
Client Height
Client 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:*
- Male
- Female
Does Spouse/Partner use tobacco?*
- Yes
- No
Spouse/Partner Date of Birth
Spouse/Partner Age*
Spouse/Partner Height
Spouse/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 Budget
- With Following Benefits & Options
Design A Plan Within The Following Budget:
Design A Plan Within Client's Budget, For:
- Self & Spouse/Partner
- Self Only
Design 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
- Thrivent
- National Guardian Life ("NGL")
Maximum Monthly Benefit
$1,500 - $15,000 (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 Inflation
1% - 5% (in 0.25% Increments)
Compound Buy-Up Options / Inflation Term
- Lifetime
- 10 Year
- 15 Year
- 20 Year
Elimination Period
- 0 day
- 30 day
- 60 day
- 90 day
- 180 day
- 365 day
Waive Elimination Period for Home Health Care?
- Yes
- No
Assisted 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)
Asset Care Plan Design:
Select how you wish the plan to be built.
- Specify Monthly LTC Benefit Amount
- Specify Premium Amount
- Specify Face Amount
Specify Monthly LTC Benefit Amount:
Specify Premium Amount
Specify Face Amount
Options range from $50,000 - $500,000
Asset Care Premium Payment Options:
For multi-year policies, all premium modes available (Annual, Semi-Annual, Quarterly, Monthly EFT).
- Single Pay (available for ages 35-80)
- Recurring Premium - 5-Pay
- Recurring Premium - 10-Pay
- Recurring Premium - 20-Pay
- Recurring Premium - Pay-To-Age 95
Asset Care AOB Duration
- 50 months
- 33 months
- 25 months (not available on Joint Policies)
Add Continuation of Benefits (COB) Rider?
- Yes
- No
COB Duration Options
- 50 months
- Lifetime
COB Duration Options
- 33 months
- Lifetime
COB Duration Options
- 25 months
- 50 months
- Lifetime
Add Inflation to COB Rider?
- Yes
- No
COB Inflation Rider Options
- No Inflation
- 3% Compound
- 5% Compound
1035 Exchange:
- Yes
- No
1035 exchange is used as premium in first year. Annualized premium must be greater than or equal to the 1035 amount.
Choose Your Plan: Plan A
Conditions 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 B
Conditions for which diagnosis would trigger benefits: Same as Plan A, EXCEPT: Heart Attack, Coronary Artery Bypass Surgery, Stroke
- Applicant
- Spouse
Choose Your Plan: Plan C
Conditions 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:
Plan Length (Months)
- 3 months
- 6 months
- 12 months
- 24 months
Elimination Period Length (Days)
- 30
- 60
- 90
Critical Illness Benefit Option Amount
($5,000, $10,000, $15,000, or $20,000)
DI Hospital Confinement Indemnity Benefit
Daily 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 Benefit
Daily 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 Budget
Client can spend up to $
Comments:

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