BROKER Broker Name (required) : Address : City (required) : State (required) : Zip Code (required) : Email Address (required) : Phone # (required) : Fax # : Return Method : Fax Mail Broker Pick-Up Email Insurance Company Preference, if any : Plan : State : CLIENT Client's Name : Birth Date : Gender : Male Female Rate Class : Preferred Standard Daily Benefit Amount : Home Care : 50% 75% 100% Benefit Period : 2 year 4 year 10 year Other If Other, Please Specify : Elimination Period (days) : 0 30 90 Other If Other, Please Specify : Inflation : Simple Compound COLI SPOUSE Spouse's Name : Birth Date : Gender : Male Female Rate Class : Preferred Standard Duplicate Benefits From Above? : Yes No If No, please complete the following: Daily Benefit Amount : Home Care : 50% 75% 100% Benefit Period : 2 year 4 year 10 year Other If Other, Please Specify : Elimination Period (days) : 0 30 90 Other If Other, Please Specify : 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 Enter the code to prove you are human: