The Return of Premium Long-Term Care Plan Analysis Request Form All required information is needed in order to send you a quote. Your Name(Required) First Last DOB(Required) MM slash DD slash YYYY Do You Smoke?(Required) Yes No Height(Required) Weight(Required) Married(Required) Yes No Spouse's Name First Last DOB MM slash DD slash YYYY Smoker? Yes No Height Weight Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical(Required)Within the past five years, have either of you been confined to a hospital, clinic, or medical facility? Yes No If Yes, Details of confinement:Have either of you been advised by a physician that you have: (Check all that apply) Hypertension Cancer Heart Disease Respiratory Disease Sleep Apnea Kidney Disorder Diabetes Stroke Details for questions 1 & 2Illustration DataWhat premium deposit option do you want us to illustrate? Single (Age 40 - 75) 5 Deposits (Age 40 - 70) 7 Deposits (Age 40 - 68) 10 Deposits (Age 40 - 65) 15 Deposits (Age 40-60) What deposit amount would you like us to use for your proposal? Soucre of funds i.e. IRAs, Cash, CDs, Annuities? How did you hear about this strategy?Eagle PublishingDr. Mark SkousenBob Carlson's Retirement WatchDr. David Eifrig's Retirement MillionaireTerry SavageFriend or Family MemberOther Yes I want to join Join over 25,000 of your Long-Term Care peers! Get articles and news delivered to your email inbox and get exclusive e-Book and report updates. This gives us permission to email you.
