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LTC Quote and Prelim Form (Test Page 2)

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  2. LTC Quote and Prelim Form (Test Page 2)

Long-Term Care Quote

Thank you for the opportunity for us to assist you with your Long-Term Care planning needs. If you complete this form, we will use the information to submit a preliminary assessment with the Long-Term Insurance Companies to determine potential eligibility and estimated rates.

Need help? Contact our Long-Term Care Specialist, Aaron Clark at aclark@ociservices.com

Agent Information

Have you completed the required 8-hour LTC training?(Required)
Have you sold a LTC policy within the last year?(Required)

We encourage you to schedule a call with one of OCI’s LTC Planning Specialists before proceeding any further. Please click the link below to schedule a call:

Reserve appointment with Aaron Clark




Please choose the OCI Sales Executive helping you with this case:

Plan Design

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

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:

Applicant Information

Applicant Name(Required)
Applicant Address(Required)
MM slash DD slash YYYY
Gender(Required)
What is the client's total approximate household Income?(Required)
Approximate total assets and investments NOT including the client's home:(Required)

Based on the information provided. You are not eligible and can stop filling out the form here
If yes, which product type? (please select all that apply):(Required)


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.
MM slash DD slash YYYY
Is surgery recommended or planned?(Required)

Individual is uninsurable until 3-6 months post-surgery.

Is the individual participating in physical therapy?(Required)

Individual is uninsurable until physical therapy is complete.

Is the individual currently receiving disability benefits?(Required)
Does the client have a history of any of the following? (please select all that apply):(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
What is the severity of the client's sleep apnea? (please select one option below)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Medication List
Exact name of Medication
Strength (Ex. 25mg or .05%)
Frequency (Ex. 2 per day)
Reason Prescribed (Ex. Blood Pressure)
 
MM slash DD slash YYYY
MM slash DD slash YYYY

Applicant Information (Second Applicant)

Applicant Name(Required)
MM slash DD slash YYYY
Gender(Required)
What is the client's total approximate household Income?(Required)
Approximate total assets and investments NOT including the client's home:(Required)
If yes, which product type? (please select all that apply):(Required)
MM slash DD slash YYYY
Does the client have a history of any of the following? (please select all that apply):(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
What is the severity of the clients sleep apnea? (please select one option below)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

If the client got sick and needed Long Term Care which asset would they liquidate first to pay for it? (Please select one)(Required)
Consent
This is not an application for LTC insurance. By checking the box you are certifying that the information completed on this form is factual to your knowledge. You are giving OCI Insurance consent to submit a preliminary assessment with the Long Term Companies to determine potential eligibility and estimated rates.

About Us

OCI

Headquartered in Elkhorn, Nebraska, OCI Insurance & Financial Services, Inc., is an insurance field marketing organization providing support to thousands of agents nationwide in the placement of these products and services.

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OCI Insurance & Financial Services, Insurance Agency, Elkhorn, NE

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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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