Broker Name

Address






Phone Number*

Fax Number*

Return Method
—Please choose an option—MailFaxE-mailBroker Pick-Up
Plan (optional)

Client State

Client Name*

Birth Date*

Sex*
MaleFemale
Rate Class*
—Please choose an option—preferredstandard
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

Spouse's Name

Birth Date

Sex
—Please choose an option—MaleFemale
Rate Class
—Please choose an option—PreferredStandard
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.