Long Term Care - Client Information and Quote Request

Select One:*

Quote Only

Quote and Appointment

Agent Phone:*

Client 1 First Name*	Client 1 Last Name*

Client 2 First Name	Client 2 Last Name

Home Phone*	Cell Phone*

Client Email:*

Preferred Appointment/Webinar Date and Time:

Client 1 Date of Birth:*

Client 1 Height*	Client 1 Weight*

Client 1 Smoker?*

Yes

Client 1 Medication (include dosage, how long):

Client 1 Hospitalizations in last 5 years? Explain:

Client 2 Spouse or Domestic Partner

Yes

Client 2 Date of Birth:

Client 2 Height:	Client 2 Weight:

Client 2 Smoker?

Yes

Client 2 Medication (include dosage, how long):

Client 2 Hospitalizations? Explain:

Have you completed the state's LTC training requirements?*

Yes

Are you currently contracted with Brokers Alliance for LTC?*

Yes

Monthly benefit:*

Benefit period:*

Inflation options:*

Elimination period:*

Payment option:*

Payment duration:*

Select the carriers you would like to quote:*

Genworth

John Hancock

Life Secure

MedAmerica

TransAmerica

United Security Assurance