Partnership Quote Request Page

LRC and Associates

1-800-443-5149

Partnership Quote Request Page

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 *
Prospects Age (last birthday) or DOB *
Rate Class to Quote
Marital Status *
Illustrate Spouse With Same Benefits
Spouse's Name
Spouse's Date of Birth (or age last birthday)
Spouse's Rate Class to Quote
Type of Coverage *
Company *
Home Care Percentage *	50% 100%
Daily Benefit Amount *
Benefit Period (Duration) *
Inflation Option
Elimination Period Option
Premium Payment Option
	Nonforfeiture
	Retun of Premium
	Supplemental Benefits
	Indemnity Rider
	Paid Up Survivorship
Additional Info./Health Conditions/Medications/Notes
What should we do with your quote?
Need An Application?
Address
Phone
Fax
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Questions?: 1-800-443-5149 - todd@lrcassoc.com