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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
Traditional LTCi Quote Request
Traditional Long Term Care Insurance Proposal Request
Δ
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, both to be insured
Has spouse or domestic Partner, but they will not be insured
Single
Insured Info Comments
MEDICAL UW INFORMATION
Medical Conditions
Any heart problem
Any kind of cancer
Diabetes
Any history of Stroke or TIA
High blood pressure or cholesterol
Back, neck or spine problems
Joint problem
Arthrirtis, Osteoporosis, or Osteopenia
Depression or Anxiety
Any other Mental/Nervous condition
None of the above
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
Premium Mode
-Select-
Annual
Semi-annual
Quarterly
Monthly - EFT
Maximum Monthly Benefit Amount
Maximum Monthly Benefit Amount 2
Maximum Monthly Benefit Amount 3
Elimination Period
O Days
30 Days
60 Days
90 Days
180 Days
365 Days
Other - please describe in comments
Benefit Period
1 years
2 years
3 years
4 years
5 years
Maximum
Other - please describe in comments
Riders
Home Care 0 Day Elimination Period
Spouse Shared Care
Inflation Benefit Increase Rider
Other - describe in comments
Inflation % Choices
5%
4%
3%
2.5%
2%
Other - describe in comments section
Inflation Term Choices
Lifetime
20 years
15 years
10 Years
Product Info Comments
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