LRC and Associates
1-800-443-5149
Under Construction
LTCi Quote Request
* Required fields
Name *
E-mail Address *
Prospect's Name *
State of Residence *
NY
- - -
AL
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AR
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CT
DE
DC
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IL
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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
What Type of Plan? *
Comprehensive LTCi
Home Care Only
Nursing Home Only
Genworth
John Hancock
MedAmerica
Mutual of Omaha
Monthly Benefit Amount *
Benefit Period *
2 years
3 years
4 years
5 years
6 years
7 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
Zipcode (if Florida)
Premium Mode
Annual
Semi-annual
Quarterly
Monthly
Premium Payment Option
Pay All Years
10 Pay
Pay to age 65
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 Number
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