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Long Term Care Quote

Agent Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Fax
Client Information
Client Name
First Last
Date of Birth
MM slash DD slash YYYY
Risk Class
- Preferred
- Standard
- Rated
Height
Weight
Has applicant ever used tobacco?
- Yes
- No
Specify type & date of last use
Medications
Medical History
Spouse Name
First Last
Spouse Date of Birth
MM slash DD slash YYYY
Spouse Risk Class
- Preferred
- Standard
- Rated
Height
Weight
Has applicant ever used tobacco?
- Yes
- No
Specify type & date of last use
Spouse Medications
Spouse Medical History
State of Residence
Benefit Amount
Is this benefit amount:
- Daily
- Monthly
Marital Status
- Married
- Single
Elimination Period (days)
- 30
- 60
- 90
- 180
- 365
Benefit Period (years)
Inflation
Home Care
- 50%
- 75%
- 100%
Non-Forfeiture Benefit
- Yes
- No
HHC Waiver?
- Yes
- No
Shared Care
- Yes
- No
Payment Options
Are you in competition for this case?
- Yes
- No
Additional Options
Comments

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About APIM

APIM is a premier distributor of life, annuity, and long-term care insurance products serving financial professionals nationwide. The company was formed solely to help independent insurance agents, financial planners, and other financial service professionals become succesful. APIM understands that its success depends on its customers’ success. View More

Contact Us

(818) 433-7952

Fax: (818) 433-7956

Address: 330 N Brand Blvd #702
Glendale, Ca 91203

Email: support@apimusa.com

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Long Term Care Quote

Client Information