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NewmanLTC Online Quote Request


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    Agent's Name: *
       

    Client Meeting Date: (mm/dd/yyyy)
       

    Agent Phone: *
       

    Agent Fax:
       

    Agent Email: *
       

    Choose method of quote delivery:
    Email      Fax      US Mail      Will Pick Up
    Day    Time

    Check here if client is single (not married/no partner).
    Check here if client and spouse/partner are applying together.
    Check here if client is married, but spouse is not applying or is uninsurable.
    Primary Insured:
       

    Date of Birth: (mm/dd/yyyy)
       

    Gender:
        Female Male

    State of Client Residence:
       

    State where App will be signed:
       

    Last Complete Physical:
       

    Last Tobacco Use:
       

    Height:
       

    Weight:
       

    List of medications and the reason for taking:
       

    List any medical conditions in the past 10 years:
       

    Secondary Insured:
       

    Date of Birth: (mm/dd/yyyy)
       

    Gender:
        Female Male

    State of Client Residence:
       

    State where App will be signed:
       

    Last Complete Physical:
       

    Last Tobacco Use:
       

    Height:
       

    Weight:
       

    List of medications and the reason for taking:
       

    List any medical conditions in the past 10 years:
       



    Please choose Traditional and/or Linked Benefit:

    Traditional and/or Linked Benefit


    TARGET PREMIUM:




    PRIMARY INSURED BENEFIT SELECTION:

    Monthly Benefit:


    Elimination Period:


    Benefit Period:


    Inflation Protection:


    SECONDARY INSURED BENEFIT SELECTION:
    Check to include Secondary Insured Benefits


    Monthly Benefit:


    Elimination Period:


    Benefit Period:


    Inflation Protection:


    Additional Riders:
    Waiver of Home Care EP
    SharedCare
    Survivorship
    Restoration of Benefits
    Calendar Day Elimination Period (not available with waiver of EP)
    Return of Premium
    Joint Waiver of Premium
    Cash Benefit (not available on all policies)
    Other:

    Company Preferences?

    Competition? Yes No
    If yes, who?


    Additional Agent Notes:




    Please choose:

    Life Products and/or Annuity Products


    Life Products
    Asset Care
    (Available to age 80) (Select One)

    Single Premium $ Asset Care I
    20-Pay Annual Premium $ Asset Care II
    20-Pay Annual Premium $ Asset Care III
    Annual Premium $ Asset Care IV

    Number of years to Pay
    (10-20 yrs)
    Lifetime

    LTC Payout as Percentage of the Death Benefit
    2% max per month per insured (50 months)
    3% max per month per insured (33 months)
    4% max per month per insured (25 months)

    Optional Continuation of Benefits (COB) Rider
    Same number of months listed above
    Lifetime (only available for 2% withdrawal)

    Optional Inflation Rider For COB coverage only
    2% Compound
    3% Compound
    4% Compound
    5% Compound
    No Inflation

    Premium for the COB Rider or Inflation Rider
    Single Premium
    Annual Premium
    10 Pay Premium



    Nationwide CareMatters (Life+LTCI)
    (Ages 40-75)

    Premium Payment Options (select one):
    Single Pay: Amount: $
    5 Pay Level Premium: Amount: $
    (Select One) Annually Monthly
    10 Pay Level Premium: Amount: $
    (Select One) Annually Monthly

    Specified Amount: $

    LTC Specified Benefit Period (select one):
    2 Years (2 yr LTC Rider Specified Accel. Period)
    3 Years (3 yr LTC Rider Specified Accel. Period)
    4 Years (2 yr LTC Rider Specified Accel. Period + 2 Yr EOB)
    5 Years (3 yr LTC Rider Specified Accel. Period + 2 Yr EOB)
    6 Years (2 yr LTC Rider Specified Accel. Period + 4 Yr EOB)
    7 Years (3 yr LTC Rider Specified Accel. Period + 2 Yr EOB)

    Inflation Options available
    3% Simple
    5% Compound



    Lincoln MoneyGuard 2?ife+LTCI
    (Issue ages: 40-79)

    Premium Payment Options (select one):
    Single Pay
    2 Years
    3 Years
    4 Years
    5 Years
    6 Years
    7 Years
    8 Years
    9 Years
    10 Years

    Premium $
           Years of benefits: (2-7 yrs) ?
    Years of benefits: (2-7 yrs)
           Monthly benefit amount $

    Flexible Premium product choices:
    (Issue ages: 30-80)
    Years of premium: (Annual payment for 3-5-7 or 10 yrs)
           Years of benefits: (2-7 yrs) ?
    Years of benefits: (2-7 yrs)
           Monthly benefit amount:$

    Inflation Options available
    3% Simple
    5% Compound
    No Inflation

    (not all inflation options available for all ages)




    Annuity Products
    Annuity Care® (Single-Premium Deferred Annuity)
    Single Premium $

    (All single premium sources) (qualified and non-qualified money may be used, however,only the Continuation of Benefits will be paid out of the annuity tax-free)

    Continuation of Benefits (COB)
    36 months
    Lifetime

    Inflation
    5% Compound



    Annuity Care II® (Single-Premium Deferred Annuity)

    Continuation of Benefits
    36 months
    72 months
    108 months

    Optional Inflation
    5% Compound
    3% Compound (not available in all states)



    Annuity Care III®

    Total Purchase Amount (TPA): $
    First Contract Premium: $

    First Contract Premium with Application: (must choose one)
    Yes
    No

    Withdrawal/Claim Method: (must choose one)
    Reimbursement
    Indemnity

    Continuation of Long-Term Care Benefits Duration: (select one):
    36 Months
    72 Months
    108 Months

    Optional Inflation Protection: (must choose one)
    No Inflation
    5% Compound Annually

    Optional Nonforfeiture Benefit: (must choose one)
    Yes
    No



    Indexed Annuity Care®

    Source of Premium:
    Nonqualified
    Qual/Traditional IRA

    Premium with Application: $
    1035 Exchange
    Transfer / Rollover
    Other

    Interest crediting methods:
    Whole percentages only. Total allocation must equal 100%.
    Indexed Account Strategies:
      Point-to-Point Cap: % - Monthly Average Cap: %
      Point-to-Point Par: % - Monthly Average Par: %
    Fixed Account: %

    Continuation of Benefits Rider:
    Single Annuitant:
    24 Months
    48 Months
    Lifetime

    Joint Annuitants or Annuitant/Eligible Person:
    30 Months
    60 Months
    Lifetime

    Payment Options:
    Single Premium
    Continuous Pay (must select mode)

    Premium Mode:
    Annual
    Semi-Annual
    Quarterly
    Monthly

    Inflation Protection Option (Choose One)
    No Inflation
    2% Compound
    3% Compound
    4% Compound
    5% Compound
    36 months



    Yes, I have read and agree to the Business Associate Agreement.
    (Business Associate Agreement 2015)


    Type the above number:










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6636 Cedar Ave. S., Suite 100
Richfield, MN 55423

Telephone: 612-454-4400 · Toll Free: 800-625-9267
Fax: 952-888-5170 · E-mail: LTC@newmanltc.com





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