Long Term Care Broker Information Broker *required Email *required Phone *required Fax Date Time of Day Needed Client Information Client Name Date of Birth Risk Class Preferred Standard Rated Medications Medical History Client Spouse Information - If Applicable Spouse Name Spouse Date of Birth Spouse Risk Class Preferred Standard Rated Spouse Medications Spouse Medical History Plan Information Benefit Amount Benefit Period Daily Monthly Elimination Period - Days 30 60 90 180 365 Benefit Period - Years 2 3 4 5 6 8 10 Lifetime Inflation None 5% Simple 3% Compound 5% Compound FPO Home Care 50% 100% Riders Share Care Refund of Premium Restoration Non-Forfeiture Survivorship, 7 year Survivorship, 10 year Carriers American General Genworth John Hancock Mutual of Omaha Additional Options Comments If you are human, leave this field blank.
