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Request for Proposal (RFP)
Agent Information  
*Name
 *State licensed for this proposal
*Phone
Fax
*Email
 *License #

*Address line 1
Address line 2
*City *State
*Zip Agency Name
 
Client Information  
*Name
 
*Date of Birth (MM-DD-YYYY)
  
Address
 
*City
 *State       *Zip
*Tobacco use in the last 5 years?
*Estimated Underwriting?
Top Preferred 2nd Preferred Standard Rated
 
Spouse/Partner Discount
No Spouse/Partner or not applying Spouse/Partner Applying
 
Note: The following section on spouse information is only required if spouse is also applying
*Spouse/Partner
*Date of Birth (MM-DD-YYYY)
Address
*City
 *State       *Zip
*Tobacco use in the last 5 years?
*Estimated Underwriting?
Top Preferred 2nd Preferred Standard Rated
 
Long Term Care Benefit Options
*Select Benefit Period (Select up to 2 Benefit Periods)
2 yrs   3 yrs  4 yrs  5 yrs 6 yrs  10 yrs  Lifetime
*Select Elimination Period
 0 Day 30 Days 60 Days 90 Days 180 Days 365 Days

 

*Select Care Option (Select one or both:)

Nursing Home? (NH) Daily Benefit Desired or,
Yes: No: Monthly Benefit Desired
 
Home Health Care? (HH)
 Daily Benefit Desired or,
Yes: No: Monthly Benefit Desired
 
*Shared Care Plan?
Yes No
(Check both NH and HH for Comprehensive Coverage) 
*Select Inflation Rider
None Simple 5% Compounded 5% Periodic/COLI None
*Companies Requested (Reimbursement) (Select up to three)
  Allianz Genworth John Hancock MassMutual
  MetLife Mutual of Omaha Prudential
*Companies Requested (Cash Indemnity) (Select up to two)
MedAmerica Prudential
 
*Payment
  Lifetime
10-Pay (Accelerated options limited by state approvals)
20-Pay
Pay to age 65
Single Pay
  
Additional
*How did you hear about us?
BenefitMall
Another Agent
Internet Search
Professional Insurance Concepts
LTCI-Partners
Other
 
Your requested proposal will be e-mailed to you in no later than 48 hours (usually within 24 hours).
To request an appointment, applications, or sales support materials, call us at 1-800-698-4210 (extension 202)