NewmanLTC Online Quote Request

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: Choose one 0 day 30 day 60 day 90-100 day 180 day 365 day Benefit Period: Choose one 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 10 Years Inflation Protection: Choose one Partnership Qualified 5% Compound 3% Compound Simple GPO None SECONDARY INSURED BENEFIT SELECTION: Check to include Secondary Insured Benefits Monthly Benefit: Elimination Period: Choose one 0 day 30 day 60 day 90-100 day 180 day 365 day Benefit Period: Choose one 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 10 Years Inflation Protection: Choose one Partnership Qualified 5% Compound 3% Compound Simple GPO None 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� Life+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)