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Proposal Request Individual Long Term Care Insurance

Please contact your Kistler Tiffany Benefits consultant with any questions.

Please fill out the following information entirely. If applicable, please provide your spouse's information in the second form.
Client Name:
Phone:
Fax:
Email Address:
State of Residence:
Date of Birth:
Height:
Weight:
Tobacco Use:


No
Health History:
(Medications, Treatments, Hospital Stays, Include Dates and Diagnosis)


Special Requests:
Plan Requested:

Benefit Period
(# of years)
Elimination Period
(# of days)
Nursing Home Benefit:
($/day)
Home Health Care:
100%        50%        of Nursing Home Benefit Amount

Inflation Protection:

None        Simple        Compound       

Tax Qualification:

Tax Qualified        Non Tax Qualified        Both       

Spouse Information:
Client Name:
State of Residence:
Date of Birth:
Height:
Weight:
Tobacco Use:

No
Health History:
(Medications, Treatments, Hospital Stays, Include Dates and Diagnosis)


Special Requests:
 
Plan Requested:

Benefit Period
(# of years)
Elimination Period
(# of days)
Nursing Home Benefit:
($/day)
Home Health Care:

100%        50%        of Nursing Home Benefit Amount

Inflation Protection:

None        Simple        Compound       

Tax Qualification:

Tax Qualified        Non Tax Qualified        Both       

 




Partners


The KTB Senior Advisory Team

You have the unique oportunity of having our knowledgeable team meet with your clients and help them with Medicare supplemental coverages as well as Long Term care Insurance.