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LONG TERM CARE We offer a wide range of Long Term Care Insurance Programs Please submit the following form to receive an illustration. Thank you! CLIENT NAME (* required) SPOUSE NAME TELEPHONE (* required) E-MAIL (* required) STATE TAX OPTION TAX QUALIFIED    NON-TAX QUALIFIED TYPE REGULAR   PARTNERSHIP INSURED SEX MALE    FEMALE SPOUSE SEX MALE    FEMALE INSURED DATE OF BIRTH Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1910 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 SPOUSE DATE OF BIRTH Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1910 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 INSURED UND. CLASS PREFERRED   STANDARD   IMPAIRED   TOBACCO SPOUSE UND. CLASS PREFERRED   STANDARD   IMPAIRED   TOBACCO INSURED ELIMINATION PERIOD 0    30    60    90    180    365 SPOUSE ELIMINATION PERIOD 0    30    60    90    180    365 INSURED DAILY BENEFIT SPOUSE DAILY BENEFIT INSURED BENEFIT PERIOD 1    2    3    4    5    6   LIFE SPOUSE BENEFIT PERIOD 1    2    3    4    5    6   LIFE INSURED INFLATION NONE    SIMPLE    COMPOUND    COLA SPOUSE INFLATION NONE    SIMPLE    COMPOUND    COLA CASH BENEFIT YES    NO MONTHLY BENEFIT YES    NO SHARED ADVANTAGE YES    NO DUAL WAIVER YES    NO SURVIVORSHIP YES    NO RESTORATION YES    NO NONFORFEITURE YES    NO MEDICAL HISTORY / DETAILS / DATES / MEDICATIONS / TREATMENT / OTHER INFORMATION