Client Name Mr. Mrs. Married Single DOB Spouse's DOB (if applicable) Smoker Non Smoker Anticipated Premium
Anticipated Benefits: 2yrs. 3yrs. 4yrs. 5yrs. Lifetime
Daily Amount Elimination Period: 0 Day 30 Days 60 Days 90 Days your fax number phone number
To receive LTC proposal within 24 hours complete and fax back. Please feel free to call Pat Bell if you have any questions. Office: 619-325-7200 Fax: 619-255-5455