Name*Date of Birth*

Gender*MaleFemaleHeight*Weight*Smoker*YesNo

Spouse Details

Spouse Name*

Date of Birth*[dob* sp_dob]Height*Weight*Smoker*YesNo

Address*

City*State*ZIP*

Policy Options

Policy Type*IndividualShared

Nursing Home Daily Benefit ($)*Nursing Home Benefit Duration*Years*

Home Health Care Coverage*50%75% - 80%100%MonthlyDaily

Elimination Period*

Inflation Protection*SimpleCompoundCPI/CompOtherNone

Riders

• Waiver of elimination Period for HHC

• Survivorship

• Joint Waiver of Premium

• Return of Premium (at Death)

• Nonforfeiture

Note all riders and/or paid up options are available with all carriers, in all states and in all combinations.

Some riders are included with some plans, if unsure do you want policies comparable?*YesNo

Special Notes

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