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General Information

Agent Name	Agent Email
Deliver Illustration via Email Fax	Date Illustration Needed
Do you need to be contracted? Yes No	Send Application / Brochure kit? Yes No
LTC CE Req's satisfied? Yes No

Client #1 Information

Name	Date of Birth
State of Residence
Offer Class Preferred Standard Rated Smoker Non-Smoker
Health Conditions
Height	Weight
List all medications and dosages
Family medical history

Client #2 Information

Name	Date of Birth
State of Residence
Offer Class Preferred Standard Rated Smoker Non-Smoker
Health Conditions
Height	Weight
List all medications and dosages
Family medical history

Please pick company & product for me

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Our recommendations

$4,500/month or $150/day for home health care, assisted living & nursing home
4 year benefit with shared care for couples when available
90 day elimination period
Compound COLA, for age 60 or younger
Compound or Simple, for ages 61-75

Choose the Benefit Details

Benefit Amount Per Month	(usually around $150/day or $4,500/month)
Length of Coverage 2 Years 3 Years 4 Years 5 Years 6 Years 10 Years Unlimited* *(Genworth/ Mutual of Omaha/Prudential Only)
Do you want Shared Care? Yes
Elimination Period 0 Days 30 Days 60 Days 90 Days 180 Days 365 Days
Home Health Care 100%
Home Health Care Elimination Zero Elim
Riders Joint Waiver of Premium Survivorship Rider Additional Cash Rider (where available)
Inflation Rider Compound COLA Simple COLA No COLA
Life Pay Annual Semi-Annual Quarterly Monthly
Limited Pay 10 Pay Paid to 65

Illustrate Specific Companies

Genworth Financial John Hancock United of Omaha Prudential Mass Mutual
Is there a partner? Yes No Even if partner is not applying, applicant may be eligible for discount.

LTC/Life Combo Products

Illustrate Specific Product
Lincoln Financial 'Money Guard Reserve' Genworth 'TLC' John Hancock Lifecare State Life Asset Care
Life/LTC Combo Policy
[ ] Face Amount $______________ (OR)	[ ] Premium Amount $______________ (OR)
[ ] Face Amount to provide $______________ per month of Long Term Care Benefits
[ ] Single Premium

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