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First Name (*)	Please let us know your name.	Last Name (*)	Invalid Input
Date of Birth (*)	/ / Invalid Input	Smoker (*)	YesNo Invalid Input
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Spouse Date of Birth	/ / Invalid Input	Smoker	YesNo Invalid Input

Your Email (*)	Please let us know your email address.
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Medical:

Within the past five years have either of you been confined to a hospital, clinic, or medical facility? (*)

YesNo

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If yes, please give details below:
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Have either of you been advised by a physician that you have (Check all that apply):

Cancer

Heart Disease

Rheumatoid Arthritis

Stroke

Diabetes

Kidney Failure

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Financial:

1. Qualified Accounts (IRA, 401K, etc): $	Invalid Input
2. Combined Annual Income: $	Invalid Input
3. Combined Net Worth: $	Invalid Input

Illustrate:

Yes Invalid Input Mr. Phillips, I am interested in finding out how I can leverage my assets today for a multiplied amount of care tomorrow. Please prepare for me, at no cost, my personalized Leveraged Care Solution Analysis based on the following information:

Which Leveraged Care Solutions would you like us to illustrate?

LTC/Annuity ComboIndividualJoint Invalid Input

With a total lump sum deposit of :

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Life Legacy/LTC Combo (Individuals Only) YesInvalid Input

With a lump sum deposit of :

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or with an annual deposit of

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for

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years

LTC/Life Combo (Individuals Only) Yes Invalid Input

With a lump sum deposit of :

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