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Long Term Care Questionnaire SECTION I: AGENT INFORMATION * Full Name of Agent Address Line 1 Address Line 2 City, State, Zip * E-Mail * Business Phone Cell Phone Home Number Fax Number SECTION II: APPLICANT INFORMATION Applicants name: Applicants Date of Birth: Applicants Sex: Male Female Applicants Height Weight (if weight changed in the last 12 months, please indicate) Has the applicant used tobacco in the last 12 months? Yes No Quote a preferred class on the applicant? Yes No Applicant Married? Yes No SECTION III: Joint Client Information Joint applicants name: Joint applicants Date of Birth: Joint applicants Sex: Male Female Joint Applicants Height Weight (if weight changed in the last 12 months, please indicate) Has the joint applicant used tobacco in the last 12 months? Yes No Quote a preferred class on the joint applicant? Yes No Joint Applicant married? Yes No SECTION IV: Quote Information State of quote: Company(s) requested: Daily benefit [monthly]: Elimination Period 0 30 50 60 90 100 180 Benefit period: 1 2 3 4 5 6 7 8 Life Inflation: Compound Simple Futures Purchase Option None HHC amount: 0% 50% 75% 100% HHC indemnity? Yes No HHC waiver of Elimination Period? Yes No Payment options Annual Semi-Annual Quarterly Monthly Pre-payment options 10 Pay Single Pay Pay to 65 Return of premium: None Full Full Less Claims Paid Shortened SECTION V: Case Information Is your client a business owner? (LTCi premium can be deductible; IRC Sections 162 & 213): Yes No Are you in competition for this case? Yes No If yes, please specify Additional comments or health concerns?