Long Term Care Quote Request

Agent Name:*

Agent Company:

Agent Email*

Agent Phone*

Have you completed the required 8-hour LTC training?*

Yes
No

Have you sold a LTC policy within the last year?*

Yes
No

Insured Name:*

Date of Birth:*

Height*

Weight*

Gender*

Male
Female

State*

Tobacco Use?*

Yes
No

Outside of the primary residence, what is the total amount of assets for this individual?*

Is the insured married?*

Yes
No

Will insured's spouse be applying for coverage?*

Yes
No

Spouse Name:*

Spouse Date of Birth:*

Spouse gender:*

Male
Female

Spouse height*

Spouse weight*

Does spouse use tobacco?*

Yes
No

Plan Design

Type of Product*

Payment Mode*

Payment mode funding source*

Benefit Length:*

Monthly Benefit Amount:*

Elimination Period:*

Premium Tolerance: Have you discussed how much your client is expecting/willing to pay for this coverage?*

Yes
No

Annual premium client can/is willing to pay?*

Please contact lifesales@ociservices.com to discuss our split case program to have one of our LTC specialists work directly with you and your client.

Optional Benefits/RIders:

3% Inflation Protection
5% Inflation Protection
Shared Care
Waiver of Elimination Period for HHC
Return of premium (if added on a traditional LTC policy expect premium to roughly double)

Health History

Over 45% of Long Term Care cases are rated or declined. Eliminate the surprise for your client and increase your closing percentage by asking your client about any known health conditions.

Has the individual had an application for life, disability, or long term care insurance declined, modified or rated?*

Yes
No

If yes, provide additional information:*

Is the individual currently receiving disability benefits?*

Yes
No

If yes, provide additional information:*

Provide medical history for past 10 years. Please provide condition, date of occurence and outcome:*

List any prescription medications taken during the past two years (including prescribed reason):*

Additional Comments - Please note if you discussed this case with an OCI sales representative.

Note: This is not an application for LTC insurance.