The Ark Group
Your Partner In Success!
Long Term Care Illustration Request
Agent Name:
Phone Number:
Fax Number:
E-mail:
Would you like this quote:
Agent Information:
Client Information:
Name:
DOB:
Age:
State:
Rate Class:
Tobacco:
Daily Benefit Amount:
Home Care Percentage:
Benefit Period:
Elimination Period:
Inflation Protection:
Corporation:
Other Benefit:
Is Your Client:
If spouse is applying, the Spouse Information section is required.
Spouse Information:
Name:
DOB:
Age:
State:
Rate Class:
Tobacco:
Daily Benefit Amount:
Home Care Percentage:
Benefit Period:
Elimination Period:
Inflation Protection:
Other Benefit:
Pre-Underwriting/Additional Comments:
Please list any known health conditions, medications, dosages and/or hospitalizations during the past 5 years:
