Producer Information
 

Name: 

Phone: 

 (area) (xxx-xxxx)

Fax: 

 (area) (xxx-xxxx)

Please Send My Proposal By: 

  Fax
 Email
Email:
(required)
 
 
 Client Information:
 

Client 1:
Name:
Birth Date: / /  (mm/dd/yyyy)
Gender: Male Female
Residential Status: Married Single
Partner Shared Residence
State of Residence:
Tobacco Use: Yes No
Medications and Dosages: Listed Below None
 
Medical History: Listed Below None
 
Underwriting Class Requested: Preferred Standard
other:
Height:
Weight:
Has this client applied for, been issued
or been declined for LTCi in the past?:
 

Client 2
Name:
Birth Date: / /   (mm/dd/yyyy)
Gender: Male Female
Residential Status: Married Single
Partner Shared Residence
State of Residence:
Tobacco Use: Yes No
Medications and Dosages: Listed Below None
 
Medical History: Listed Below None
 
Underwriting Class Requested: Preferred Standard
other:
Height:
Weight:
Has this client applied for, been issued
or been declined for LTCi in the past?:
 
 Type Of Coverage Requested:
 

Reimbursement Indemnity Cash
 
 Illustration:
 
State of Policy Issue:

Benefit Period:

 1 2 3 4 5
6 7 10 Lifetime

Benefit Design:

Benefit Amount:

Home HealthCare:

0% 50% 75% 100%

Elimination Period:

0 Days 20/30 Days 50/60 Days
90/100 Days 180 Days 365 Days

Inflation Riders:

None CPI Simple
Compound 3 Compound 5
 

 Additional Riders:

Shared Care
Return of Premium
Restoration of Benefits
Waiver of Premium
Uninsurable Spouse
Survivorship
Zero Day EP for Home Care
Other
 

 Regular Payment Modes:

Annual Semi-Annual
Quarterly Monthly

 Limited Payment Plans:

10 Pay Premium
20 Pay Premium
Paid up at age 65
 

 Additional Instructions:

Is this a partnership case? Yes No
Special Instructions
 
 Carrier Selection

 
Would you like the SDIC Marketing Team to suggest the one carrier we feel provides the best value for your client?

Yes No

(If you select NO, multiple quotes will be provided)

 

An illustration cannot be provided unless this form is fully completed.
 
   
 
 
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