LONG TERM CARE QUOTING TOOL Long-Term Care Quote Request "*" indicates required fields Step 1 of 5 20% Name* First Last Phone*Email* Date of Birth:* Month Day Year Gender at Birth:* Male Female Marital Status:* Single Married Separated Divorced Widow/Widower Height and Weight:* Height Weight Nicotine Usage:*Non-nicotine must show negative on the exam, and show at least 12 month of clean history in medical records.NicotineNon-NicotineNever UsedHealth History:*Please provide a health history as much as possible so that we can determine insurability or rate class, or if none, please type "none". Medications:*Please list any current medications, including dosage and frequency in which you take them, or if none, please type "none". What type of long-term care coverage would you like to discuss?* Traditional long-term care coverage Whole/Universal life insurance with a long-term care rider Plan Design Options: Limit monthly premium up to a certain amount (we will design the plan for you based on current trends) Customize your own plan design Not sure, would like a free consultation for help with this Limit monthly premium to:Add a monthly premium limit that you would pay each month for this coverage. Most policies range from about $150mo - $500mo depending on age, benefits, medical history, etc. We will design a plan consistent to general current benefit considerations, costs, etc.Monthly facility benefit amount requested:Depending on your budget and liquid assets you have available for long-term care, please enter how much more you will need to cover care in a facility. (Range: $1,500 - $9,000mo, or $50 - $300day). Costs are dependent on type/extent of care provided. Check with local providers for costs. Policy benefit period requested:This is the amount of time that your policy will continue based on using your facility benefit every month until the policy exhausts. You can choose from 2 - 10 years, however 2 - 5 years is most common. Many facilities will allow you to remain in your current room after privately paying for 2 years before qualifying for Medicaid or other services. 2 years 3 years 4 years 5 years more than 5 years Elimination period requested:This is the amount of time before your policy starts paying, based on the inability to perform any 2 of 6 Activities of Daily Living (ADLs) for a period of at least 90 days, or an immediate severe cognitive impairment requiring either stand-by or hands-on assistance. 0 days 30 days 60 days 90 days 180 days Optional plan/benefit riders:Survivorship: (Partner benefit – when both have held a policy for 10 yrs without using it, and one partner passes, the surviving partner will not have to pay future premiums). Waiver of Premium: No premiums are due while receiving benefits. Restoration of Benefits: If long-term care is no longer needed after 180 days, maximum lifetime benefits are restored. Shared Care: Benefit carry-over from identical policies in the event of a partner’s policy exhaustion. Non-Forfeiture: Coverage continued on a reduced basis in the event premium payment ends. Return of Premium: A refund of all premiums paid, less claims paid, will be returned upon death. Please note, optional riders may increase monthly premiums. Survivorship Waiver of Premium Restoration of Benefits Shared Care Non-Forfeiture Return of Premium How much life insurance coverage?Typically, face values start at $50k and go up from there, with a maximum allowance based on annual gross income. The LTC rider can reimburse up to 4% of the face value monthly for qualifying LTC expenses.Please enter a number from 50000 to 50000000. Consent* I agree to the privacy policy.By checking this box, you grant permission to Benefit Solutions Plus to contact you in the future associated with topics, products and or services within our industry.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
