Long Term Care Quote Request Broker Information Agent Name *required Address City, State, Zip Code Email Address *required Business Phone *required Cell Phone Home Phone Fax Client Information Applicants Date of Birth Applicants Name Applicants Sex Male Female Does the applicant use tobacco? None Cigarette Cigar Chew Quote a preferred class on the applicant? Yes No Tax Bracket Client Two Information Second Applicants Date of Birth Second Applicants Name Second Applicants Sex Male Female Does the second applicant use tobacco? None Cigarette Cigar Chew Quote a preferred class on the second applicant? Yes No Quote Information State of quote Primary Objective Death Benefit Cash Accumulation Guarantees Low Premium Other Objectives/Needs Key Man Split Dollar Buy Sell 101J Business Owned Kettley Description Vital Signs Face Amount(s) Specified Carrier Product Information Whole Life? Single Premium Full Pay Term ART 5 10 15 20 25 30 Permanent? UL Survivor UL VUL SVUL Permanent - Desired Interest Rate Permanent - Alternate Interest Rate Payment Options Annual Semi-Annual Quarterly Monthly Suspend Pay Suspend Pay - Cash Value Suspend Pay - At Age Suspend Pay - Years Payment Plans Payment Plans - 1035 Exchange Payment Plans - Lump Sum SECTION VIII: RIDERS Riders - Child Rider Riders - Waiver of Premium Yes No Riders - ADB Yes No Case Information Are you in competition for this case? Yes No If yes, please specify: Additional comments or health concerns? If you are human, leave this field blank.