Company
(Use Ctrl or Shift
to choose multiple) |
|
| Product |
Long Term Care
RWJ-Partnership LTC
Home Care (only)
|
| Type |
Tax-Qualified
Non-Tax-Qualified
|
| IRBA (Association) Discount (10%) |
yes no
|
|
| APPLICANT |
| Name |
|
| DOB (or age LAST birthday) |
|
| Marital Status |
|
| Rate Class |
Preferred
Select (Standard)
Rated Class I
Rated Class II
PrefPlus (Allianz)
|
| Daily or Monthly Amount |
daily monthly
|
| Benefit Period |
2 Years
3 Years
4 Years
5 Years
|
| |
6 Years
7 Years
10 Years
Lifetime (Unlimited)
|
| Waiting Period |
0 Days
20 Days
30 Days
45 Days
|
| |
60 Days
90 Days
100 Days
180 Days
|
| Inflation Option |
None
5% Simple
5% Compound
|
| |
5% Compound X 2
COLI Rider
|
| State |
Zipcode (if Florida)
|
| Premium Mode |
annual semi-annual quarterly monthly
|
Premium If
Limited Pay |
Pay All Years 10 Pay
Pay to age 65 Other
|
|
| SPOUSE |
| Name |
|
| DOB (or age LAST birthday) |
|
| Rate Class |
Preferred
Select (Standard)
Rated Class I
Rated Class II
PrefPlus (Allianz)
|
| Daily or Monthly Amount |
daily monthly
|
| Benefit Period |
2 Years
3 Years
4 Years
5 Years
|
| |
6 Years
7 Years
10 Years
Lifetime (Unlimited)
|
| Waiting Period |
0 Days
20 Days
30 Days
45 Days
|
| |
60 Days
90 Days
100 Days
180 Days
|
| Inflation Option |
None
5% Simple
5% Compound
|
| |
5% Compound X 2
COLI Rider
|
| Premium Mode |
annual semi-annual quarterly monthly
|
Premium If
Limited Pay |
Pay all years 10 Pay
Pay to age 65 Other
|
|
| Additional Information |
|
What should we do with it?
(Select more than one if you wish) |
E-mail Full Proposal
Fax Full Proposal
E-mail Page One Only
Fax Page One Only
Mail Full Proposal
Mail Applications/Materials
|
|
| Name |
|
| Business |
|
| Address |
|
| City |
|
| State/Prov. |
|
| Zip/Postal Code |
|
| Phone |
|
| FAX |
|
| E-mail |
|
