Life Insurance

Access Brokerage Services	14 Roosevelt Avenue Port Jefferson Sta., NY 11776 (631) 473-7244
"Access to Life Products, Access to Quality Service, Access to Top Compensation"	info@accessbrkg.com

Long Term Care

Client Name
Client Date of Birth
Is the client a smoker?	Yes No
Is Spouse Applying for Coverage?	Yes No
Spouse Name
Spouse Date of Birth
Is the spouse a smoker?	Yes No
Marital Status
Coverage Information
Nursing Home Daily Benefit Amount
Home Health Care Benefit	50% 80% 100%
Elimination Period (days)	0 20/30 60 90/100
Benefit Period (years)
Inflation Option	None 5% Simple 5% Compound
Underwriting Information
If applicant is NOT 'normal' weight, please specify	Spouse 1: Height Weight Spouse 2: Height Weight
Is there existing coverage?	Spouse 1 Spouse 2
If there is existing coverage is this a replacement	Spouse 1 Spouse 2
Please Describe Underwriting Concerns
Other Comments or Concerns
Broker Contact Information
Broker Name
How would you like to be contacted?	Mail Fax Email
Broker Phone
Broker Fax Number
Broker Email Address
Broker Street Address
City, State, Zip