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.