Lanny D. Levin Agency; http://www.levinagency.com - Request an LTC Quote

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REQUEST LONG TERM CARE INSURANCE QUOTE

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Your Information
Your Name:
Your Company:
Your Address:
Your City:
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Your Zip:
Your Phone Number:
Your Fax Number:
Your E-mail Address:	E-Mail Me A Copy of This Proposal
Your LTC Specialist:

Primary Insured		Spouse/Partner
	Insured's Name
	Date of Birth
	State
	Height
	Weight
Male Female	Gender	Male Female
	Last Tobacco Use
	Surgeries past 5 yrs

Daily Benefit:
Benefit Duration:
Elimination Period:
Benefit Type:

Available
Riders:

	3% Inflation Protection
	5% Inflation Protection
	Return of Premium (pays a beneficiary the total premiums less claims paid at the death of the insured)
	Shortened Benefit Period (an enhanced non-forfeiture option)
	Paid Up Survivor Benefit Rider (Joint policy only)
	Personal Caregiver Rider (when care is provided by a non-professional, unpaid family member or friend)

Has the client been treated for any of the following conditions in the last 5 years?
Primary Insured	(check all that apply)	Spouse / Partner
	High Blood Pressure
	Heart Attack, Angina, Angioplasty or Atria Fibrillation
	Stroke or TIA
	Arthritis
	Type I Diabetes (insulin)
	Type II Diabetes (oral meds)
	Neuropathy or Retinopathy
	Osteoporosis (list T-Score below)
	Compression Fractures
	PSA (prostate test) for men (list score below)
	Cancer (list type and treatment below)
	Fibromyalgia
	Anxiety/Depression
	Lupus (list type below)

Please list other health issues or any relevant details on above conditions Also, please list any prescription Meds & Dosages, with Reason prescribed
Primary Insured	Spouse/Partner

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600 central avenue, suite 333, highland park, illinois 60035