LONG TERM CARE QUOTE
Producer Name:
Email:
Phone Number:
State:    Partnership Policy
Companies to be quoted
(select all that apply)		   GE  John Hancock 
  Prudential  MetLife 
Client:
Client Date of Birth: //  or  Age:
Client Height/Weight:
Client Tobacco: Yes  No Married:: Yes  No
Client Medical History/
Medications:
Spouse:
Spouse Date of Birth  //  or  Age:
Spouse Height/Weight:
Spouse Tobacco: Yes  No
Spouse Medical History/
Medications:
Coverage Type:
Daily Benefit Amount:
Elimination Period:
Benefit Duration:
Inflation Type:
Accelerated Payment Options:
Return of Premium
Additional Comments: