AGIS Insurance Center - Long Term Care

Primary
Name:	First: Last:
E-Mail address:
Phone numbers:	Daytime:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
Best time to call:
Address:
City:
State:
Zip code:
Do you currently own your home, or rent?	Own Rent
Driver's license number:
Social security number:
Birthdate:
Sex:	Male Female
Rate Class:	Preferred Standard
Daily Benefit Amount:
Home Care:	50% 75% 100%
Benefit Period:	2 Years 4 Years Lifetime Other
Elimination Period (Days):	0 30 90 Other
Inflation:	Simple Compound COLI
Spouse
Name:
Birthdate:
Sex:	Male Female
Rate Class:	Preferred Standard

Duplicate Benefits From Primary?	Yes No

If no, please complete the following:
Daily Benefit Amount:
Home Care:	50% 75% 100%
Benefit Period:	2 Years 4 Years Lifetime Other
Elimination Period (Days):	0 30 90 Other
Inflation:	Simple Compound COLI
Pre-Underwriting:
Please list any additional comments, as well as any significant health conditions, associated medications AND/OR hospitalizations in the last 5 years.

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AGIS Insurance Center, Inc.
165 Bishops Way Suite 120
Brookfield, WI 53005
Phone: 262-641-9800
Email:AGIS.HOME@agisins.com

Hours of Operation

Monday - Friday 8:30am to 5:00 pm CST
Or by Appointment