LONG TERM CARE QUOTE Broker Name Address Phone Number* Fax Number* Return Method ---MailFaxE-mailBroker Pick-Up Plan (optional) Client State Client Name* Birth Date* Sex* MaleFemale Rate Class* ---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 ---MaleFemale Rate Class ---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.