Brass Ring Financial Solutions
Long Term Care Insurance Center
Stand Alone Long Term Care
Linked Benefit Plan – Long Term Care with Annuity or Life Insurance
LONG-TERM CARE INSURANCE PROPOSAL REQUEST
Broker Name______________________________________________________
Telephone # ( ) _____________________________________________
Fax # ( ) __________________
Email Address__________________________________________
CLIENT INFORMATION
Client Name(s): __________________________________________ D.O.B. ______________________
State of Residence: _____________________
Client A Client B Shared Care?
DOB ____________ DOB _____________ Y___ N____
Monthly Maximum or Daily ¬¬ ___________¬¬¬_ ____________ __________
Benefit Period ____________ ____________
2yr, 3yr, 4yr, 5, yr, 6yr, 7yr, 8yr, 10yr
Lifetime (Unlimited)
Elimination Period ____________ ____________
30, 60, 90,180 or 365
Optional Benefits
Inflation Protection 5% Compound ______ 3% Compound________
5% Simple _________ CPI ________
GPO ________ GPO _______
0-Day HHC Elim. Period ____________
Return of Premium __________ Survivor Benefit __________ Restoration of Benefits _______
Premium Mode – Standard (Lifetime) _________ Pay to Age 65 __________ 10 Pay __________
Monthly___ Quarterly ___ Semi-annual ___ Annual ___ Lump Sum ___ $ Amount _________
Illustrate as a Linked Benefit Plan using ___ Life Insurance ___ Annuities
Current Medical Treatment________________________________________________
__________________________________________________________
Any restrictions on Activities of Daily Living?
__________________________________________________________
Comments
___________________________________________________________
___________________________________________________________
Please submit the LTCi Quote information via email:
John C. Massolio III, CLU ChFC
john@brassringfinancial.solutions
888-651-0025
We will provide you the best quotes from the industry’s leading carriers.