Long Term Care Quote Request

Schedule a LTC Consultation with OCI's Planning Specialist:
Reserve appointment with Aaron Clark

Agent Name:*

Agent Company:

Agent Email*

Agent Phone*

Have you completed the required 8-hour LTC training?*

Yes
No

Have you sold a LTC policy within the last year?*

Yes
No

We encourage you to schedule a call with one of OCI’s LTC Planning Specialists before proceeding any further. Please click one of the links below to schedule a call:

Reserve an appointment with Dan Dahl
Reserve appointment with Aaron Clark

Is your client shopping for a rate? We'll make it easy! Click one of the below links for a simple rate calculator:

1. Traditional LTC
2. Individual Linked Benefit
3. Joint (Couples) Linked Benefit

Please choose the OCI Sales Executive helping you with this case:*

Insured Name:*

Date of Birth:*

Height*

Weight*

Gender*

Male
Female

State*

Tobacco Use?*

Yes
No

Outside of the primary residence, what is the total amount of assets for this individual?*

Is the insured married?*

Yes
No

Will insured's spouse be applying for coverage?*

Yes
No

Spouse Name:*

Spouse Date of Birth:*

Spouse gender:*

Male
Female

Spouse height*

Spouse weight*

Does spouse use tobacco?*

Yes
No

Plan Design

Type of Product*

Payment Mode*

Payment mode funding source*

Benefit Length:*

Monthly Benefit Amount:*

Elimination Period:*

Premium Tolerance: Have you discussed how much your client is expecting/willing to pay for this coverage?*

Yes
No

Annual premium client can/is willing to pay?*

Please contact lifesales@ociservices.com to discuss our split case program to have one of our LTC specialists work directly with you and your client.

Optional Benefits/RIders:

3% Inflation Protection
5% Inflation Protection
Shared Care
Waiver of Elimination Period for HHC
Return of premium (if added on a traditional LTC policy expect premium to roughly double)

Case Design Notes - specific product, carrier, goal of case, etc. Please note if you discussed this case with an OCI sales representative or if you’re in competition with another carrier.

Health History

Over 45% of Long Term Care cases are rated or declined. Eliminate the surprise for your client and increase your closing percentage by asking your client about any known health conditions.

Is surgery recommended or planned?*

Yes
No

Individual is uninsurable until 3-6 months post-surgery.

Is the individual participating in physical therapy?*

Yes
No

Individual is uninsurable until physical therapy is complete.

Has the individual had an application for life, disability, or long term care insurance declined, modified or rated?*

Yes
No

If yes, provide additional information:*

Is the individual currently receiving disability benefits?*

Yes
No

If yes, provide additional information:*

Provide medical history for past 10 years. Please provide condition, date of occurence and outcome:*

List any prescription medications taken during the past two years (including prescribed reason):*

Additional Comments - Please note if you discussed this case with an OCI sales representative.

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Note: This is not an application for LTC insurance. By clicking Submit, I certify all information is true and accurate to the best of my knowledge.