LONG TERM CARE - Quote Request

Would you like First Resource Group to help you take a look at some LTCi products for your client? Just complete the Quote Request Form and we will email/fax you an easy-to-read columnar comparative analysis of products, features, and premiums that are available. The analysis is suitable to use when presenting to a client.

Simply fill out the form below and email to us, or Click here to print this form and fax it in.


Contact Information
NAME:
PHONE:
EMAIL:
FAX:
TELL US ABOUT YOUR CLIENT
Recent Decline: Yes No
Name:

DOB (MM/DD/YY):

State:




Married: Yes No
Spouse Care Partner Applying: Yes No
Spouse Name     Spouse DOB
Carrier Prefence:
Notable Health Concerns
Medications
Include dosage and length of treatment
CHOICE OF BENEFITS
Maxmum Daily Benefit:
Plan Duration: 3 4 5 6 8 10 Unl
Elimination Period (Days): 0306090180
Waive Elimination for HHC: YesNo
Assisted Living: 50%60%70%80%100%
Profeesional HHC : 100% 200% 300%
CHOICE OF OPTIONS
Benefit Increase Options 2.5% 3.0% 3.5% 4.0% 4.5% 5.0% Compounded

5.0% Compounded - 10 Years
5.0% Compounded - 20 Years

CPI Compounded

5.0% Compounded - Double Max

5.0% Simple

5.0% Guaranteed Purchase Option
Spouse Related Options: Shared Care Spouse Security
Spouse Waiver of Premium/Survivorship Waiver of Premium
Return of Premium FullLess Claims
Pay Period: Lifetime10 Pay20 Pay

Pay to Age 65Single Pay
BENEFIT PAYMENTS
Reimbursement of Incurred Charges

Cash regardless of Incurred Charges

Reimbursement w/some cash
IS THERE COMPETITION?
Company
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