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OneSource Brokerage, Inc.                

 

 
 

LTC QUOTE

Agent Information
Agent Name:   

 
Phone:   

 
Fax:   

 
Email:   

 
Application
Sign State:		   

 

Before presenting or selling long-term care insurance, please make sure that you hold your Life & Health License in the appropriate states and have completed any necessary LTC or State Partnership requirements.
 

Client Information
Client Name:   

   
Birth Date:   
//
   
Gender:   
Male  Female
   
Height:   
Weight:   
State of Residence:   

   
Tobacco Use:   

   
Medical History /
Medication:		   

   
Client is:   
Single  Married
 
 

Spouse Information

Spouse Name:   

   
Birth Date:   
//
   
Gender:   
Male  Female
   
Height:   
Weight:   
Tobacco Use:   

   
Medical History /
Medication:		   

   
 

Policy Information
State Partnership Policy:    
   
    Yes  No 
   
   
Policy Type:		    
Benefit Amount:   
   
Elimination Period:		   
   
Benefit Period:		   
   
Inflation Protection:		   
   
Payment Options:		   
Riders:   
0 Day Home Care   Return of Premium
 Shared Care            Restoration of Benefits
 Nonforfeiture         Joint Waiver of Premium
    
Carriers: Genworth John Hancock Mutual of Omaha
Prudential TransAmerica
Additional Information:   
 
Delivery Information
   
How would you
like to receive:		    
   
   
Email  Fax
   
   
This quote is needed by:		    
   
   
//
   
 


If we have all information needed to accurately
quote your client, please expect your proposals
within 24 hours. If otherwise, we will contact you.