Victorson Associates Inc

Long Term Care Quote Request

Broker Submitting Quote Request:
First Name:		City
Last Name:		State
Company:		Zip
Street Address 1:		Phone#:
Street Address 2:		Fax#:
		E-Mail:

Client:		Age:
DOB:		Smoker?
Spouse:		Age:
DOB:		Smoker?
Is the spouse applying for coverage now?
If no Spouse is named above, is the client currently married?
Is your client interested in the NY State Partnership plan?
Daily Benefit Amount:		Waiting Period:

Benefit Period Desired:
Home Health Care Percentage:
Inflation Option
Do you want to see alternate Benefit Options on the illustrations?

Please indicate any specific insurance companies you would prefer. (Ctrl-click on each carrier requested):
Does either the Client or Spouse have any medical condition that could effect underwriting adversely? (if so, please fill in information below):

Please indicate All Medications being taken and who is taking it:

Please feel free to leave any information below about a specific product or Long Term Care feature that you would like to see:

Supplies Requested With Quote: Send Supplies?	Yes No
Are you appointed with Victorson Assoc. and the carrier?	Yes No
Do you wish your proposal sent to you by: Mail Fax E-Mail