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Home
Agent Tools
Doing Business with DIL
Needs Analysis
Life Quotes
LTC | DI | Annuity Quotes
Forms
XRAE Underwriting Tool
Underwriting Tools
Contracting & Licensing
Policy Service
Core Carriers
Sales & Marketing
Annuity
Disability
Long Term Care
Life Insurance
Blog
About
About Us
Meet the Team
Contact Us
Your Life Department
Life/LTC Hybrid Quote Request
Order Number
AGENT INFO
Agent First Name
*
Agent Last Name
*
Agent Primary Phone Number
*
Agent Alternate Phone Number
Agent Email Address
*
Agent License #
*
PROPOSED INSURED INFO
Proposed Insured First Name
*
Proposed Insured Last Name
*
State of Residence
*
- Select Province/State -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
====================
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
Date of Birth
*
Gender
*
Male
Female
Height
Weight
Nicotine Use
*
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)
please check the most accurate option
Marijuana Use
*
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
Please indicate details of any marjuana use in comments
Partner Status
Has spouse or domestic Partner
Single
Please check one. If spouse to be insured, please complete separate quote request form for him or her.
Insured Info Comments
Please provide other pertinent information or details from questions above
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
Please check any treated or diagnosed conditions and indicate details below under Medical History Details
Disability History
Yes
No
Has this client been disabled in the last 5 years?
Handicap Placard
Yes
No
Has this client been allowed a handicap placard or parking permit in the last 12 months?
Assistive Devices
Yes
No
Does this client need to use an assistive device such as a cane or walker, even occasionally, or been told they need to by their doctor?
Nursing, Assisted Living or Rehabilitation Facility
Yes
No
Has this client ever been confined to an Assisted Living, Nursing or Rehabilitation Facility? If yes, please provide details in Medical History Details
Medications
Yes
No
Has this client been prescribed any medications?
Medical History Details
Please provide approximate dates and details of any history of medical issues requiring prescription medication, hospitalizations or other treatments
Medical UW Info Comments
Please provide other pertinent information or details from questions above
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
Choose one
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
Click in box to choose inflation options
Product Info Comments
Please enter other pertinent information or details from questions above
File Upload
Upload
Please upload in documents relating to this request
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