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Long Term Care Quote Request

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Long Term Care Quote

Schedule a LTC Consultation with one of OCI's Planning Specialists:
Reserve appointment with Dan Dahl
Reserve appointment with Nick Elbert
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
We encourage you to schedule a call with one of OCI’s LTC Planning Specialists before proceeding any further. Please click one of the links below to schedule a call:
https://oci.appointlet.com/b/nick-elbert
https://oci.appointlet.com/b/dan-dahl
Is your client shopping for a rate? We'll make it easy! Click one of the below links for a simple rate calculator:
1. Traditional LTC
2. Individual Linked Benefit
3. Joint (Couples) Linked Benefit
Insured Name:*
Date of Birth:*
Date Format: MM slash DD slash YYYY
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:*
Date Format: MM slash DD slash YYYY
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)
Case Design Notes - specific product, carrier, goal of case, etc. Please note if you discussed this case with an OCI sales representative or if you’re in competition with another carrier.
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.
Is surgery recommended or planned?*
- Yes
- No
Individual is uninsurable until 3-6 months post-surgery.
Is the individual participating in physical therapy?*
- Yes
- No
Individual is uninsurable until physical therapy is complete.
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. By clicking Submit, I certify all information is true and accurate to the best of my knowledge.

About Us

Headquartered in Omaha, Neb., OCI Insurance & Financial Services, Inc., is an insurance and employee benefits general agency. The company provides support to thousands of agents nationwide in the placement of these products and services.

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402.330.8700
Toll free: 866.320.8700
Fax: 402.330.8706

4221 N. 203rd St, Ste 200
Elkhorn, NE 68022

Hours:
Monday – Thursday: 8:00 am – 5:00 pm
Friday: 8:00 am – 4:30 pm

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