Individual Long Term Care Insurance Request for Proposal
Please fill out the following information entirely. If applicable, please provide your spouse's information in the second form.
Information:
KTB Associate:
Producer Name:
Phone:
Facsimile:
Email Address:
Client Name:
State of Residence:
Date of Birth:
Height:
Weight:
Tobacco Use:
(Yes or No)
Health History:
(Medications, Treatments, Hospital Stays, Include Dates and Diagnosis)
Special Requests:
Plan Requested:
Benefit Period
(# of years)
Elimination Period
(# of days)
Nursing Home Benefit:
($/day)
Home Health Care:
100%
50%
of Nursing Home Benefit Amount
Inflation Protection:
None
Simple
Compound
Tax Qualification:
Tax Qualified
Non Tax Qualified
Both
Spouse Information:
Client Name:
State of Residence:
Date of Birth:
Height:
Weight:
Tobacco Use:
(Yes or No)
Health History:
(Medications, Treatments, Hospital Stays, Include Dates and Diagnosis)
Special Requests:
Plan Requested:
Benefit Period
(# of years)
Elimination Period
(# of days)
Nursing Home Benefit:
($/day)
Home Health Care:
100%
50%
of Nursing Home Benefit Amount
Inflation Protection:
None
Simple
Compound
Tax Qualification:
Tax Qualified
Non Tax Qualified
Both