Fiduciary Intermediary Ltd. - Long Term Care

Individual Name:

Age:

Spouse Name:

Age:

Address:

City:

State:

Zip:

Phone:

Fax:

Broker:

Broker Phone Number:

Fax Number to Send Rates to:

Request Effective Date:

Martial Status:

Married Single

Benefit Amount:

$200 $300
Other: $

Elimination Period:

90 Days 180 Days
Other: Days

Benefit Period:

3 Years 5 Years
Other: Years

Inflation Rider:

Yes No

Home Care%:

50% 100%
Other: %

Please let us know of any specific medical conditions:
i.e. Diabetes, type I etc..