LRC and Associates
1-800-443-5149
Under Construction
CASH LTCi Quote Page
Note:
We will include all the available options in your quote - check off what you'd like to see on page one.
* Required fields
Name *
E-mail Address *
Prospect's 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
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ND
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OK
OR
PA
RI
SC
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UT
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VA
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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 *
Comprehensive
Nursing Home Only
Home Care Only
Company
MedAmerica
Payment Option
Lifetime Payment
10 Pay
Cash Benefit Account Choice
$200,000
$300,000
$500,000
$1,000,000
Home Care Monthy Benefit
$4,500
$6,000
$7,500
$9,000
$12,000
Nursing Home Monthly Benefit
$6,000
$7,500
$8,000
$9,000
$10,000
$12,000
$16,000
Elimination Period
30 Days
60 Days
90 Days
180 Days
Inflation Option
None
Simple 5%
Compound 5% X2
Compound 3% No Max
Compound 5% No Max
Return of Premium Option
None
Return Of Premium
Full Return Of Premium
Shortened Benfit Period
Restoration of Benefits
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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Privacy Policy
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Any Questions?
1-800-443-5149
or
todd@lrcassoc.com
