American Insurnet A Cincinnati Company
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LONG TERM CARE QUOTE
Required fields are marked with an asterisk.
Agent Information

Agent Name:*
Phone:*
Fax:
Email:*

How would you like your quote returned to you?  Email  Faxed  Mailed
Client Information

Client:
State of Res.
DOB:
Sex:  Male  Female
Tobacco Use?  Yes  No
Married?
Is spouse applying for coverage?

Known health condition (include onset dates, treatment, and medications):


Daily benefit amount?
($100 - $450):

Qualified:  Non-Qualified:

Elimination Period:
0  30  60  90  365

Benefit Period:
2  3  4  5  6  Lifetime

Home Health Care %:
0  50  75  100

Non - Forfeiture Rider:
Indemnity  Single Pay
RDP  Limited Pay

Automatic Benefit Increase Rider (5%):
Simple  Compound  CPI

Please provide the following spouse information if applying for spousal coverage:

Name:
State of Res.
DOB:
Sex:  Male  Female
Tobacco Use?  Yes  No

Known health condition (include onset dates, treatment, and medications):

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American Insurnet Agency, Inc.644 Linn Street, Suite 1100Cincinnati, OH 45203800.333.4638