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LTC Quote and Prelim Form (Test Page)

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  2. LTC Quote and Prelim Form (Test Page)

Long-Term Care Quote and Preliminary Questionnaire

Step 1 of 2

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Need help? Email Aaron Clark LTC Specialist


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 one of the links below to schedule a call:

Reserve an appointment with Dan Dahl
Reserve appointment with Aaron Clark

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



MM slash DD slash YYYY
Gender:(Required)
Tobacco Use:(Required)
Is the insured married?(Required)
Will the insured's spouse be applying for coverage?(Required)
Does spouse use tobacco?

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:

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?(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.

Has the individual had an application for life, disability, or long term care insurance declined, modified or rated?(Required)
Is the individual currently receiving disability benefits?(Required)

Long-Term Care Preliminary Questionnaire

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.
Are you working with an OCI Team member currently? (Please pick 1, if no one select other)

Agent Information

Applicant Information

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

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

If NO, please continue filling out the form.

If yes, which product type? (please select all that apply):(Required)
MM slash DD slash YYYY
Do you 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 your 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 your total approximate household Income?(Required)
Approximate total assets and investments NOT including your home:(Required)
If yes, which product type? (please select all that apply):(Required)
MM slash DD slash YYYY
Do you 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 your sleep apnea? (please select one option below)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

If you got sick and needed Long Term Care which asset would you 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

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

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