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Long-Term Care Insurance Decline--Preliminary Data Form

Please complete the questions below. This form will be submitted directly to our in-house underwriting team to determine which long-term care insurance alternative (if any) might be appropriate for your client. We will respond to you as fast as possible and let you know what options are available. -Chris Hynes

Client's First Name *

Client's Date of Birth (or Age) *

Tobacco User? *

Monthly long-term care benefit desired? *

Duration of benefit (for eg., 3 years, 5 years etc)? *

Summary of reason for the decline? * Be brief but thorough. Include any medical information that you feel is relevant to the decline.

Your name/phone/email address *



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