Preferred Marketing Associates - insurance plans for health, dental, disability, life, retirement and long term care

Preferred Marketing Associates Long Term Care
* denotes required field
Broker Information

Broker Contact Information	*Name:
	Phone:
	*Email:
Client Information

Primary Applicant Information	*Name:
	*Gender:		*Tobacco:
	*DOB:	(dd/mm/yyyy)
	*Height:		*Weight:
	*Married:	Yes No
	Health:

Spouse Information ( if applying )	Name:
	Gender:		Tobacco:
	DOB:
	Height:		Weight:
	Health:
Long Term Care Quote

Benefit Type	Monthly Daily
Benefit Amount
Benefit Period
Elimination Period
Preferred Premium Range
Optional	Return of Premium Spousal Discount Spouse Shared Care Spouse Waiver of Premium Spouse Survivorship Inflation Protection
Special Instructions

Preferred Marketing Associates, Ltd.
3530 North 163rd Plaza
Omaha, NE 68116

Ph. (402) 397-9787
Toll Free 1-800-777-0723