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Client Name Mr. Mrs.

Married Single DOB

Spouse's DOB (if applicable)

Smoker Non Smoker Anticipated Premium

Anticipated Benefits: 2yrs. 3yrs. 4yrs. 5yrs. Lifetime

Daily Amount

Elimination Period:   0 Day 30 Days 60 Days 90 Days

your fax number phone number

To receive LTC proposal within 24 hours complete and fax back.
Please feel free to call Pat Bell if you have any questions.
Office: 619-325-7200  Fax: 619-255-5455