Diane Steeves - Request A Quote

Diane Steeves - Request A Quote

In order to create your own Long Term Care (LTC) plan, you need to answer the questionnaire below and submit it.

Policy Format
CLIENT #1

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Client #1 Client #1 First Last
Client #1 - Date Of Birth Client #1 - Date Of Birth / MM / DD YYYY
Client #1 - Smoker?
Client #1 - Current Medications (name & purpose)
Client #1 - Surgeries/Hospitalization (past 5 years)
CLIENT #2

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Client #2 Client #2 First Last
Client #2 - Date Of Birth Client #2 - Date Of Birth / MM / DD YYYY
Client #2 - Smoker?
Client #2 - Current Medications (name & purpose)
Client #2 - Surgeries/Hospitalization (past 5 years)
PLAN DETAILS

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Daily Benefits ($40 - $500/per day)
Waiting Period (the amount you cover before benefits)
Payment Length
Inflation Protection
CONTACT INFORMATION

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Contact Name Contact Name First Last
Preferred Contact Method
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Email
Message