BPS

All Long Term Care Insurance plans are NOT created equal. To compare the premiums of our carriers to each other or to other popular plans in the market, please fill out and submit the following form.

Producer Information
* Indicates a Required field

* Name:

Agency:

* Phone: (include area code)

* Fax: (include area code)

* E-mail:

* Carriers to Compare (Please select up to 6 carriers)
Allianz
Assurity
Genworth
John Hancock
MedAmerica
MetLife
Mutual of Omaha
Prudential

Other(s)

Client Information

Name:

* Date of Birth or Age:

* Gender:
Male Female
* Rate Class:
Preferred Standard
* Daily Benefit Amount:

* Home Care:
50% 75% 100%
* Benefit Period:
3 yr. 5 yr Lifetime Other
* Elimination Period (days):
0 30 90 Other
* Inflation:
Simple Compound None

Spouse Information

Name:

Date of Birth:

Gender:
Male Female
Rate Class:
Preferred Standard

Duplicate Benefits from above?
Yes No

If No, please complete the following:

Daily Benefit Amount:

Home Care:
50% 75% 100%
Benefit Period:
3 yr. 5 yr Lifetime Other
Elimination Period (days):
0 30 90 Other
Inflation:
Simple Compound None

Pre-Underwriting
Please list any additional comments, as well as any significant health conditions, associated medications and/or hospitalizations in the last 5 years. Also please include any special instructions.