Home > Insurance Services

Long Term Care Insurance Quote Form
Bank Name
Referred By
Date		5/9/2008 3:17:16 PM
Client Information
Name
Date of Birth						Age
Smoker						Yes		No
Marital Status
Is the client's spouse applying?						Yes		No
Spouse's Name
Date of Birth						Age
Smoker						Yes		No
Client's Resident State
State where application will be signed
If an application is signed in a state other than the client's resident state, a valid reason must be provided.
Policy Options
Nursing Home Daily Benefit ($)
Nursing Home Benefit Duration (Years)
Home Health Care Coverage							50%		75%/80%		100%
Elimination Period
Inflation Protection Option							Simple		Compound
							CPI		None
Special Notes
Medical Conditions Treated in the Past 10 Years										Add One
1	Condition							Date of Onset
2	Condition							Date of Onset
3	Condition							Date of Onset
Medications Currently Taking										Add One
1	Medication							Dosage
Taken For								Times/Day
2	Medication							Dosage
Taken For								Times/Day
3	Medication							Dosage
Taken For								Times/Day
Hospitalizations in the Past 10 Years										Add One
1	From					To
Reason
Result
2	From					To
Reason
Result
3	From					To
Reason
Result
Please note: SCBA will quote a standard rate unless a completed Medical History Information/Form is provided along with this Quote Request Form. Please fax completed form to the SCBA at (803) 799-8090. Questions? Contact the SCBA at (803) 799-0850 or IQ@scbankers.org. You may also access this form at www.scbankers.org. Thank you for your business!