LTC Quote Request Form
SECTION I: AGENT INFORMATION
   
*Full Name of Agent:
   
Address Line 1:
Address Line 2:
City, State and Zip:
   
*Email Address:
   
*Business Phone:
Cell Phone:
Home Phone:
   
Fax Number:
   
* = Required Field  
   
SECTION II: APPLICANT INFORMATION
Applicant's Name:
Applicant's Date of Birth:
Applicant's Sex: Male
Female
Has the applicant used tobacco in the last 12 months? Yes
No
Quote a preferred class on the applicant? Yes
No
SECTION III: Joint Client Information
Joint applicant's name:
Joint applicant's Date of Birth:
Joint applicant's Sex: Male
Female
Has the joint applicant used tobacco in the last 12 months? Yes
No
Quote a preferred class on the joint applicant? Yes
No
SECTION IV: Quote Information
State of quote:
Company(s) requested:
Daily benefit: Monthly
Elimination Period:
Benefit period:
Inflation:
HHC amount: 0%
50%
75%
100%
HHC indemnity? Yes
No
HHC waiver of Elimination Period? Yes
No
Payment options Annual
Semi-Annual
Quarterly
Monthly
Pre-payment options 10 Pay
Single Pay
Pay to 65
Return of premium:
SECTION V: Case Information
Is your client a business owner? (LTCi premium can be deductible; IRC Sections 162 & 213): Yes
No
Are you in competition for this case? Yes
No
I don't know
If yes, please specify
Additional comments or health concerns?

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a division of ING Financial Partners, Inc.
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Diversified Underwriters Services Inc., is not a subsidiary of nor controlled by VLBD/ING Financial Partner, Inc.

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