Note:  You must be partnership certified in order to talk to clients about the partnership plans.   Here's a link to the NYS Partnership Agent training site: http://www.nyspltc.org/agents/ where you can get information on how to become certified.

* Required fields
Name *
E-mail Address *
	Check here to verify that you are partnership certified.
Prospects Name *
State of Residence *	NY -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Prospects Age (last birthday) or DOB *
Rate Class to Quote	Best Preferred Rate Standard Rate Sub-Standard Rate
Marital Status *	Married/Spouse Applying Married/Spouse Not Applying Single
Illustrate Spouse With Same Benefits	Yes No: (Fill out seperate quote request and Submit)
Spouse's Name
Spouse's Date of Birth (or age last birthday)
Spouse's Rate Class to Quote	Best Preferred Rate Standard Rate Sub-Standard Rate
Type of Coverage *	Total Asset 50 Total Asset 100 Dollar for Dollar 50 Dollar for Dollar 100 Total Asset I(6/6/100) (Hancock) Total Asset II(4/4/100) (Hancock) Total Asset III(3/6/50) (Hancock) Dollar for Dollar I (2/2/100)-(Hancock) Dollar for Dollar II (1.5/3/50)-(Hancock)
Company *	Genworth MedAmerica
Home Care Percentage *	50% 100%
Daily Benefit Amount *
Benefit Period (Duration) *	548 Days/1.5 Years 730 Days/2 Years 1095 Days/3 Years 1460 Days/4 Years 1825 Days/5 Years 2555 Days/7 Years
Inflation Option	5% Compound 5% Simple (not available at all ages) None (Age 80+)
Elimination Period Option	Calendar Day Enhanced Elimination Period
Premium Payment Option	Standard - Lifetime 10 Year Premium Payment Premium Paid Up at age 65 Double-Pay First Year Reduced Pay at age 65
	Nonforfeiture
	Retun of Premium
	Supplemental Benefits
	Indemnity Rider
	Paid Up Survivorship
Additional Info./Health Conditions/Medications/Notes
What should we do with your quote?	E-mail Full Proposal Fax Full Proposal E-mail Page One Only Fax Page One Only Mail Full Proposal
Need An Application?	No Yes-Email Yes-Snail Mail
Address
Phone
Fax

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Questions?: 1-800-443-5149 - todd@lrcassoc.com