LONG TERM CARE QUOTE

    Or

    Pool of Money Desired

    Elimination Period
    0 days30 days60 days90 daysOther

    Inflation Rider
    3%5% Compound5% SimpleOther

    Other Riders
    Shared CareCalendar DayOther

    Spouse's Name

    Birth Date

    Sex

    Rate Class

    Daily or Monthly Benefit Amount

    Home Care %

    Benefit Period
    2 year3 year4 year5 yearLifetimeOther

    (or)

    Pool of Money Desired

    Elimination Period
    0 days30 days60 days90 daysOther

    Inflation Rider
    3%5% Compound5% SimpleOther

    Other Riders
    Shared CareCalendar DayOther

    Pre-Underwriting

    Please list any additional comments, as well as any significant health conditions, associated medications AND/OR hospitalizations in the last 5 years, i.e. ht/wt if out of normal range, cancer, heart, arthritis, etc.