The Return of Premium LTC Plan Analysis Request Form First Name (*) Please let us know your name. Last Name (*) Invalid Input Date of Birth (*) MonthJanFebMarAprMayJunJulAugSepOctNovDec / Day01020304050607080910111213141516171819202122232425262728293031 / Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 Invalid Input Smoker (*) YesNo Invalid Input Spouse First Name Invalid Input Spouse Last Name Invalid Input Spouse Date of Birth MonthJanFebMarAprMayJunJulAugSepOctNovDec / Day01020304050607080910111213141516171819202122232425262728293031 / Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 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) HypertensionRespiratory DiseaseSleep ApneaDiabetesCancerHeart DiseaseKidney DisorderStroke 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 captcha"> CAPTCHA* Are You Human? Request ROPLTC Analysis
