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

Agent Name(Required)

Agent Company

Agency Affiliation

Agent Email(Required)

Agent Phone(Required)

Have you completed the required 8-hour LTC training?(Required)

Yes

Have you sold a LTC policy within the last year?(Required)

Yes

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:

Darwin Couch

Aaron Clark

Joe Gordon

Plan Design

Type of Product:(Required)

Payment Mode:(Required)

Payment Mode Funding Source:(Required)

Benefit Length:(Required)

Monthly Benefit Amount:(Required)

Elimination Period:(Required)

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

Yes

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.

Annual premium client can/is willing to pay?(Required)

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.

Applicant Information

Applicant Name(Required)

First Last

Applicant Email Address(Required)

Applicant Phone Number(Required)

Applicant Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

State of Residency:(Required)

Date of Birth:(Required)

Height:(Required)

Weight:(Required)

Gender(Required)

Male

Female

What is the client's total approximate household Income?(Required)

Under $50,000

$50,001-$75,000

$75,001-$125,000

$125,001-$225,000

$225,001+

Approximate total assets and investments NOT including the client's home:(Required)

Under $50,000

$50,001-$100,000

$100,001-$350,000

$350,001-$500,000

$500,001-$1,000,000

$1,000,001+

What is the primary reason/goal the client is requesting Long-Term Care coverage?(Required)

Is the client receiving or has the client received any disability insurance benefits or social security disability benefits?(Required)

Based on the information provided. You are not eligible and can stop filling out the form here

Has the client previously been declined or rated for Long Term Care, Life, or Disability Insurance? (Yes or No)(Required)

When and what insurance type was the client declined or rated for? (Long Term Care, Life, or Disability)

Does the client have a Long-Term Care Insurance plan in force now? (Yes or No)

Does the client plan to replace your policy if a new one is approved?

If yes, which product type? (please select all that apply):(Required)

Life Insurance

Disability Insurance

Long-Term Care Insurance

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 client used Tobacco in the last 12 months?(Required)

If Yes, last date of use

What kind of tobacco?(Required)

Is surgery recommended or planned?(Required)

Yes

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

Is the individual participating in physical therapy?(Required)

Yes

Individual is uninsurable until physical therapy is complete.

Is the individual currently receiving disability benefits?(Required)

Yes

If yes, provide additional information:(Required)

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

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.

Does the client have a history of any of the following? (please select all that apply):(Required)

Date of Occurence

What type of Cancer was the client diagnosed with?

What is the date treatment was completed?

What type of diabetes was the client diagnosed with?

When was the client diagnosed?

What was the client's last known A1C reading?

What is the date of onset?

What is the severity of the client's sleep apnea? (please select one option below)

Mild

Moderate

Severe

Has the client been prescribed a Cpap machine, BiPAP, or dental device to use?

If yes, are you currently using it?

If yes, what type of procedure?

What was the outcome of the procedure?

If yes, what type?

What was the date of the procedure?

What was the date of last treatment?

Has the client received more than 2 injections a year for your neck or back?

Has the client had 2 or more prior back surgeries with ongoing chronic /recurrent back pain requiring treatment?

Has the client been hospitalized in the last 5 years for depression?

Is the client currently seeing a Psychiatrist?

If yes, what was the approximate date?

What is the name of the client's immune system disease?

What date was the client diagnosed?

Any prescription medication taken during the past 2 years?(Required)

Medication List

Exact name of Medication

Strength (Ex. 25mg or .05%)

Frequency (Ex. 2 per day)

Reason Prescribed (Ex. Blood Pressure)

Please list any significant medical event during the clients lifetime?

Date of last cardiac test?

Were two or more of the client's siblings or biological parents (FORMALLY) diagnosed with any type of Dementia?

Has the client had a physical check-up with your health care provider in the last 2 years?(Required)

If yes, what was the approximate date?

Is the client Single or Married?

Is the client's Spouse interested in Long Term Care Coverage? (NOTE: Discounts may apply when both apply for coverage**)(Required)

Applicant Information (Second Applicant)

Applicant Name(Required)

First Last

Applicant Phone Number(Required)

Applicant Email Address(Required)

State of Residency(Required)

Date of Birth(Required)

Height(Required)

Weight(Required)

Gender(Required)

Male

Female

What is the client's total approximate household Income?(Required)

Under $50,000

$50,001-$75,000

$75,001-$125,000

$125,001-$225,000

$225,001+

Approximate total assets and investments NOT including the client's home:(Required)

Under $50,000

$50,001-$100,000

$100,001-$350,000

$350,001-$500,000

$500,001-$1,000,000

$1,000,001+

What is the primary reason/goal the client is requesting Long-Term Care coverage?(Required)

Is the client receiving any disability insurance benefits?(Required)

Has the client previously been declined for insurance coverage?(Required)

If yes, which product type? (please select all that apply):(Required)

Life Insurance

Disability Insurance

Long-Term Care Insurance

Has the client used Tobacco in the last 12 months?(Required)

If Yes, last date of use

Does the client have a history of any of the following? (please select all that apply):(Required)

Date of Occurence

What type of Cancer was the client diagnosed with?

What is the date treatment was completed?

What type of diabetes was your client diagnosed with?

When was the client diagnosed?

What was the clients last known A1C reading?

What is the date of onset?

What is the severity of the clients sleep apnea? (please select one option below)

Mild

Moderate

Severe

Have you been prescribed a Cpap machine, BiPAP, or Dental device to use?

If yes, are you currently using it?

If yes, what type of procedure?

What was the outcome of the procedure?

If yes, what type?

What was the date of the procedure?

What was the date of last treatment?

Has your client received more than 2 injections a year for your neck or back?

Has the client had 2 or more prior back surgeries with ongoing chronic /recurrent back pain requiring treatment?

Has the client been hospitalized in the last 5 years for depression?

Is the client currently seeing a Psychiatrist?

Any prescription medication taken during the past 2 years?(Required)

If Yes, please list the following: 1) Name of medication(s) 2) dose of medication(s) 3) reason it was prescribed. Please list ALL 3 for each prescription.(Required)

Please list the client's significant medical event during their lifetime?

Date of last cardiac test?

Were two or more of client's siblings or biological parents (FORMALLY) diagnosed with any type of Dementia?

Has the client had a physical check-up with their health care provider in the last 2 years?(Required)

If the client got sick and needed Long Term Care which asset would they liquidate first to pay for it? (Please select one)(Required)

Checking/Savings Account(s)

Investments

Old Annuities

IRA/401K

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