Long Term Care Quote

Client #1 Information

Client #1: Name*

Client #1: Date of Birth*

Quote to save age?

Yes
No

Client #1: Gender*

Male
Female

Client #1: State of Residence*

Client #1: Marital Status*

Client #1: Tobacco Use*

Yes
No

Medical Information

Client #1: Medications and Dosages

Client #1: Medical History

List details above

Client #1: Underwriting Class Requested

Preferred
Standard

Client #1: Height

Client #1: Weight

Client #1: Has this client applied for, been issued or been declined for LTCi in the past?

Yes
No

Client #1: Details

Client #2 Information

Client #2: Name

Client #2: Date of Birth

Client #2: Gender

Male
Female

Client #2: State of Residence

Client #2: Marital Status

Client #2: Tobacco Use

Yes
No

Medical Information

Client #2: Medications and Dosages

Client #2: Medical History

List details above

Client #2: Underwriting Class Requested

Preferred
Standard

Client #2: Height

Client #2: Weight

Client #2: Has this client applied for, been issued or been declined for LTCi in the past?

Yes
No

Client #2: Details