Call: (888) 892-1102

The Return of Premium LTC Plan

Analysis Request Form

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

Your Email (*)	Please let us know your email address.
Phone Number (*)	Invalid Input	Best Time To Call	Invalid Input

Address (*)	Invalid Input
City (*)	Invalid Input	State (*)	Invalid Input	Zip Code (*)	Invalid Input

Medical:

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

YesNo

Invalid Input

If yes, please give details below:
Invalid Input

Have either of you been advised by a physician that you have: (Check all that apply)

Hypertension

Respiratory Disease

Sleep Apnea

Diabetes

Cancer

Heart Disease

Kidney Disorder

Stroke

Invalid Input

Illustration Data:

What premium deposit option do you want us to illustrate?

Single (Age 40 – 75)

5 Deposits (Age 40 – 70)

7 Deposits (Age 40 – 68)

10 Deposits (Age 40 – 65)

15 Deposits (Age 40 – 60)

Invalid Input

What deposit amount would you like us to use for your proposal?

Invalid Input

Source of funds i.e. IRAs, Cash, CDs, Annuities?

Invalid Input

BE THE FIRST TO KNOW:
Opt-in to stay informed with the latest updates Invalid Input

About Us

Estate Planning Specialists, LLC was established in 1988 to help effectively serve the estate planning needs of the many nationwide clients of companies of David T. Phillips and Co.; Insurance Quote Services, and Phillips Financial.

The Return of Premium LTC Plan

Analysis Request Form

Medical:

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

Illustration Data:

What premium deposit option do you want us to illustrate?

What deposit amount would you like us to use for your proposal?

Source of funds i.e. IRAs, Cash, CDs, Annuities?

About Us

Latest News