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"LONG TERM CARE/
ILLUSTRATION REQUEST"

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LONG TERM CARE / ILLUSTRATION REQUEST
Please contact me: 

 
BROKER INFORMATION
First Name..: Last Name..:
Telephone..: Extension...:
Fax.............: Email.........:
CLIENT # 1 INFORMATION
#1 Name.: Sex: Male Female
State of Residence...: Date of Birth....:
Smoker: No Yes      (If Yes) - Cigarettes Pipe Cigar
Rate: Prefer Standard Smoker
KNOWN HEALTH ISSUES OR MEDICATIONS
Diabetes, Arthritis, Hypertension, Coronary Artery Disease, etc.
REQUESTED COVERAGE FOR CLIENT # 1
NURSING HOME: HOME HEALTH CARE:
Daily Benefit...........:  Daily Benefit...........: 
Benefit Period........:  Benefit Period........: 
Elimination Period.:  Elimination Period.: 
Inflation Protection - None COLA Simple Compound
Tax Qualified? Yes No
Association Discount?    If so, Name..:
CLIENT # 2 INFORMATION
#2 Name.: Sex: Male Female
State of Residence...: Date of Birth....:
Smoker: No Yes      (If Yes) - Cigarettes Pipe Cigar
Rate: Prefer Standard Smoker
KNOWN HEALTH ISSUES OR MEDICATIONS
Diabetes, Arthritis, Hypertension, Coronary Artery Disease, etc.
REQUESTED COVERAGE FOR CLIENT # 2
NURSING HOME: HOME HEALTH CARE:
Daily Benefit...........:  Daily Benefit...........: 
Benefit Period........:  Benefit Period........: 
Elimination Period.:  Elimination Period.: 
Inflation Protection - None COLA Simple Compound
Tax Qualified? Yes No
Association Discount?    If so, Name..:
ADDITIONAL REQUESTS OR COMMENTS:





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