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Home
Agent Tools
Doing Business with DIL
Needs Analysis
Life Quotes
LTC | DI | Annuity Quotes
Underwriting Forms
XRAE Underwriting Tool
Underwriting Tools
Contracting & Licensing
Policy Service
Core Carriers
Sales & Marketing
Annuity
Disability
Long Term Care
Life Insurance
About
About Us
Meet the Team
Contact Us
Your Life Department
Life/LTC Hybrid Quote Request
Asset Based LTC & Life/LTC Hybrid Proposal Request
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AGENT INFO
Agent First Name
Agent Last Name
Agent Email Address
Agent License #
PROPOSED INSURED INFO
Proposed Insured First Name
Proposed Insured Last Name
State of Residence
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date of Birth
Gender
Male
Female
Height
Weight
Nicotine Use
-Select-
No use of any type ever
No Cigarette use for 5+ years
No Cigarette use for 3+ years
No Cigarette use for 12+ months
Cigarette use in last 12 months
Cigar use only
Chewing tobacco use only
Nicotine gum/patch only
Other (explain below)
Marijuana Use
-Select-
No use ever
No use in last 5 years
No use in last 12 months
Use 5-7 times per week
Use 1-3 time per week
Use occasionally - please define below
Partner Status
Has spouse or domestic Partner
Single
Insured Info Comments
MEDICAL UW INFORMATION
Medical Conditions
Any heart problem
Any kind of cancer
Diabetes
High blood pressure or cholesterol
Back, neck or spine problems
Joint problem
Arthrirtis
Depression or Anxiety
Any other Mental/Nervous condition
Disability History
Yes
No
Disability History
Handicap Placard
Yes
No
Assistive Devices
Yes
No
Nursing, Assisted Living or Rehabilitation Facility
Yes
No
Medications
Yes
No
Prescription Medications
Medical History Details
Medical UW Info Comments
PRODUCT SELECTION
Solve For Options
Find premium required based on maximum monthly LTC benefit
Find maximum monthly LTC benefit and death benefit based on premium
Find premium and maximum monthly LTC benefit based on initial death benefit
Premium Mode
Annual
Single Payment - onetime only
Annual
Semi-annual
Quarterly
Monthly - EFT
Maximum Monthly LTC Benefit Amount
Premium Amount
Death Benefit Amount
Premium Payment Period
Single Pay - onetime Payment
Pay all years - pay for life
5 years
10 years
20 years
To age 65
Other - please describe in comments
Maximum Benefit Period
2 years
3 years
4 years
5 years
50 months - Life/LTC Hybrid only
6 years
7 years
Lifetime - AssetCare only
Inflation Options
5%
3%
None
Other - describe in comments section
Product Info Comments
File Upload
Choose File
Submit Proposal Request
