Applicant Data Name: Birthdate (mm/dd/yyyy): Tobacco Usage? Yes No Height: (ex. 5'7") Weight (lbs.) Please list any prescription medications the applicant is currently taking. List any medical condition the applicant has had over the last five years. State: Second Applicant Data 2nd Applicant Name: Birthdate (mm/dd/yyyy): 2nd Applicant Tobacco usage? Yes No 2nd Applicant Height: 2nd Appicant Weight:: Please list any prescription medications the applicant is currently taking. List any medical condition the applicant has had over the last five years. Contact Information Phone Number: Fax Number: Email Address: Mailing Address: Benefit Options Daily Benefit Desired $100$110$120$130$140$150$160$170$180$190$200$210$220$230$240$250$260$270$280$290$300$200$300 Elimination Period: 0 days30 days90 days180 days How much time will elapse before benefits start? Benefit Period: 3 years4 years5 yearsLifetime How long will the benefits last? Payment Options: 10 Pay - You make ten payments of 10% of your policy value. Lifetime - Your make steady payments throughout your lifetime until you begin using your policy. Paid up at 65 - You with to pay for your policy in full by age 65 then make no payments thereafter. Optional Benefit Riders Benefits Reimbursement - You or your family pays for expenses then file a claim with us. Indemnity - We pay expenses directly. Compound Inflation Rider A compound inflation rider will allow the value of your policy to annually increase to account for rising costs due to inflation. None 3% 5% Return of Premium If you die (last of your deaths under joint coverage) while the Policy is in force the total premiums paid reduced by the total of benefits received will be paid to your beneficiary. There will be no additional fefund of premiums as described under the Refund of Unearned Premium provision in the Policy. Yes No Paid-Up Survivor In the event that two partners are insured the policy has been in effect for ten years and one partner has died the policy will be considered paid-up for the surviving partner. If one partner has died but the policy had not yet been in effect for ten years the surviving partner's premium will be recalculated to the rate charged for an individual policy for the balance of the ten-year period. Yes No Waiver of Premium If you or your partner are incapacitated for 90 days premium payments will no longer be due until recovery. Yes No Previous Declination Have you been declined for long-term care insurance in the past by any insurer? Yes No Unknown If yes when were you declined? Which insurer declined you? Why were you declined? Additional Comments/Questions If you have any questions or comments about this application enter them in the field below. You can also give us a call at 707-822-7251 during normal business hours. Do not enter anything in this field: