Fields indicated with an asterisk * are required.

Broker Submitting Quote Request

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First Name

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Last Name

Company:

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Phone

Extension

Fax

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Email

Address

City

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State

—Please choose an option—ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP

Client Information

Client

Age

DOB

Smoker

—Please choose an option—NoYes

Spouse

Age

DOB

Smoker

—Please choose an option—NoYes

Is the spouse applying for coverage now?  —Please choose an option—NoYes

If no spouse is named above, is the client currently married?  —Please choose an option—NoYes

Is your client interested in the NY State Partnership Plan?  —Please choose an option—NoYes

Daily Benefit Amount: 

Waiting Period:  —Please choose an option—0 days20 days60 days90 or 100 days

Benefit Period Desired:  —Please choose an option—2 years3 years4 years5 years6 yearsUnlimited Benefits

Home Health Care Percentage:  —Please choose an option—100% of Nursing Home Benefit80% of Nursing Home Benefit75% of Nursing Home Benefit50% of Nursing Home BenefitNo Home Health Care Benefit

Inflation Option:  —Please choose an option—NoneCPI - No initial premium costSimple Inflation5% Compound Inflation

Do you want to see alternate benefit options on the illustrations?  —Please choose an option—NoYes

Please indicate any specific insurance companies you would prefer:
Mutual of OmahaNational Guardian Life

Does the client or spouse have any medical condition(s) that could adversely affect underwriting?  —Please choose an option—NoYes

If yes, please give details.

Please indicate all medications being taken and who is taking it.

Please indicate below any information about a specific product or long-term care feature you would like to have included:

Need supplies?  —Please choose an option—NoYes

Supplies requested:

Are you appointed with Victorson Associates and the carrier?  —Please choose an option—NoYes