Long Term Care Analysis

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First Name

Last Name

Email Address

Age

Gender

Pricing requires your birth sex.

Smoking Status

Select smoker if you have used any nicotine products in the past 3 years.

Assumed Earnings Rate:

Death Benefit and LTC Coverage Amount

This is the amount of hybrid death benefit and long term care coverage amount that you want to apply for.

Preferred Premium Payment Schedule

You can choose to pay premiums for 15 years or to your age 100 (lifetime).

Select all of the following medical conditions that you have been treated for or diagnosed with in the past 10 years

Are you a diabetic?Is your BMI (Body Mass Index) significantly above or below normal ranges?Do you or have you had any significant heart issues?This information is used only for the analysis report. The numbers provided in the analysis report in no way reflect any insurance company underwriting decisions. This generic information is used in an attempt to provide estimated cost and benefits of the policy.

Do you require assistance performing the activities of daily living (e.g. bathing, continence, eating, dressing, toileting, or transferring)? Or, do you use respiratory equipment or dialysis or need assistance with walking? Or, are you eligible for or receiving disability benefits?