Pre-Qualification Request for Quote

Agent Name:State: Client Name: Date of Birth:­ Height:Weight: Any use of tobacco products in the last 5 years? YN Do you have a medical history of, or currently have, any of the following conditions? Abdominal, cerebral or thoracic aneurysmYN Cancer of Internal organs YN Chronic Respiratory Disease (Asthma, COPD, Sleep Apnea)YN Circulatory Disease (Carotid Artery, Coronary Artery, Vascular)YN Depression or AnxietyYN DiabetesYN Fibromyalgia, Chronic Fatigue SyndromeYN Heart DiseaseYN Joint ReplacementYN Macular Degeneration, BlindnessYN Continued on next page

OsteoporosisYN Restless Leg Syndrome, TremorsYN Arthritis, Rheumatoid ArthritisYN Seizure DisorderYN Transient Ischemic Attack (TIA), Retinal Occulsion, StrokeYN Ulcerative Colitis, Crohn’s Disease, Gastric BypassYN Detail of Chronic Conditions: Condition NameDiagnosis Date Continued on next page

Medications:Diagnosis Date: Are your average blood pressure readings greater than 135/85?YN Are you currently receiving, or have you received any disabilityYN benefits with the past 12 months? Within the past 12 months, have any surgeries or diagnostic testsYN been recommended but not performed? Have you been declined, postponed, or rated for LTC Insurance?YN If yes above, reason? Please return to: Mary Sizemore, CLTC LTC Solutions LTCS (5827) Fax #

Information Needed for a Quote:  Agent’s Name, Telephone # & Address  Client’s Name, DOB, Marital Status & State of Residence  Carrier of Interest  Daily or Monthly Benefit  Benefit Period (Multiplier)  Elimination Period  Inflation Protection  Additional Riders