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Agent Name
Email
Phone
Client A Information
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Height
Weight
State of Residence
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Guam
Hawaii
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Maryland
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Northern Mariana Islands
Ohio
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Pennsylvania
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South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Marital Status
Single
Married
Partner for 3+ Years
Risk Class
Preferred
Standard
Rated
Nicotine Use
No
Yes
Business Owner?
No
Yes
Notes
Client B Information
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Height
Weight
State of Residence
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Marital Status
Single
Married
Partner for 3+ Years
Risk Class
Preferred
Standard
Rated
Nicotine Use
No
Yes
Business Owner?
No
Yes
Notes
Traditional LTCI Quote Information
Benefit Amount
Inflation Options
3% Compound
5% Compound
Premium Mode
Annual
Semi-Annual
Quarterly
Monthly
Elimination Period
0 Days
30 Days
60 Days
90 Days
180 Days
365 Days
Duration of Benefits
2 Years
3 Years
4 Years
5 Years
6 Years
8 Years
Lifetime
Riders
HHC Elimination Period Waiver
Shared Care
Spousal Waiver of Premium
Return of Premium
Spousal Security Benefit
Single Pay
10 Pay
Lifetime Pay
Comments
Asset-Based Hybrid LTCI Quote Information
Solve For
Monthly Benefit Amount
Premium Amount
Benefit/Premium Amount
Duration of Benefits
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
Lifetime
Inflation Options
3% Compound
5% Compound
Premium Payment
Lifetime Pay
Single Pay
Limited Pay
Premium Mode
Annual
Semi-Annual
Quarterly
Monthly
Source of Funds (Single Pay)
If 1035 Exchange, Enter Cost Basis
Notes
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