For assistance call 1-800-842-7799

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   Normal / Prepare by End of Day    Please call me to discuss my case

APPOINTMENT
DATE & TIME
 
STATE
 
AGENT NAME
 

Prefered method of contact: Phone   Fax   Email
**Be sure to enter "Method of Contact" info below.**
PHONE
  
EMAIL
  
FAX
  
Let GOLDENCARE USA be your back office! Our Marketing Team can run the numbers you need through our list of carriers. We can quote the right company,even if your client has/had:Congestive Heart Failure,Severe Emphysema,Parkinsons,Severe Diabetes,Heart Attack or Stroke. We can even help with declines. Please provide any information you have - missing information is not generally an issue.
TELL US ABOUT YOUR CLIENT(S)
Name  
Date of Birth
 
Height
  
Weight
  
Smoker
  Yes  No

Previous Decline
  Yes  No
Married
   Yes  No
Health History
(within last five years)
Medications
(include dosage and length of treatment)
Spouse Applying Yes  No
Spouse's Name
 
Date of Birth
  
Height
  
Weight
  
Smoker
  Yes  No

Previous Decline
  Yes  No
Health History
(within last five years)
Medications
(include dosage and length of treatment)

 

OPTION #1 - DESIGN A PLAN WITHIN A CLENT'S BUDGET

Client can spend up to
$ (monthly)
For:
Self and Spouse  Self Only

 

- OR -

OPTION #2 - QUOTE ON PLAN WITH FOLLOWING BENEFITS & OPTIONS

Carrier Preference
 
Most Competitive Carrier
Yes  No

 

CHOICE OF BENEFITS
Maximum Daily Benefit
 
Plan Duration
  Years     - or -       Unlimited
Elimination Period
(days)
  0  30  60  90  180

Waive Elimination for HHC (days)
  Yes  No
Is Waiver for HHC Elimination Period Important?
  Yes  No

Assisted Living
(% of NH)
  50%  60%  70%  80%  100%

Professional HHC
(% of NH)
  100%  200%  300%  

 

CHOICE OF OPTIONS

Monthly HHC Option
  Benefits paid on monthly (instead of daily) basis

Bio Options
   Compound Lifetime 2.5%  3%  3.5%  4%  4.5%  5%
 5% Compound -10years  5% Compound -20years  5% Compound -Double Max
 5% Simple  5% Guaranteed Purchase Option
Spouse Related Options
  Shared Care  *Spouse Security  Dual Waiver of Premium/Survivorship

*Benefits for uninsured spouse
Return of Premium
   Full  Less Claims

Pay Period
  Lifetime  10 Pay 20 Pay  Pay to Age 65

 

ADDITIONAL INFORMATION

Does your client want the ability to receive care at home?

  Yes  No

Does your client want cash benefits when care provided is by voluntary care givers (family/friends)?

  Yes  No

Does your client want a rate guarantee?

  Yes  No