First Name *

Last Name *

Email *

Agent Phone Number *

Resident State * Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Resident License Number *

Applicant First Name *

Applicant Last Name *

Applicant Date of Birth *

Applicant State of Primary Residents * Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Has applicant used tobacco in the last 5 years? * Tobacco use includes the following: Any cigarettes including vapor cigarettes Pipe smoking regardless of use Cigars including celebratory (include explanation in memo at the end of form) Snuff, chew or chewing tobacco YesNo

Marital Status * Select Single Spouse/Partner not applying Spouse/Partner both applying

Carrier LTC * Mutual of OmahaNational Guardian Life LTCOneAmerica (Hybrid)

Rate Class * Preferred (Mutual of Omaha, National GuardianSelect (Mutual of Omaha, National Gaurdian)StandardClass 1 (Substandard) (25% premium rate up Mutual of Omaha)Class 2 (Substandard) (50% premium rate up Mutual of Omaha)

Monthly Benefit Amount $ *

Elimination Period * 306090180365

Benefit Period * 2 years3 years4 years5 years6 yearsLifetime (National Guardian Life)

Compound Inflation Protection * None2%3%4%5%

HHC * 100%75%50%

Riders * * If Shared Care is selected spouse/partner benefit selections will be the same. You also have to select Spouse/Partner both applying under marital status on the client information page. NoneHHC 1st day waiver of EPShared CareWaiver of PremiumJoint Waiver of PremiumNon-Forfeiture

Spouse/Partner First Name *

Spouse/Partner Last Name *

Date of Birth *

Gender * MaleFemale

Spouse/Partner State of Residence Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Has spouse/partner used tobacco in the last 5 years? * YesNo

Spouse/Partner Risk Class * Select Preferred (Mutual of Omaha, National Guardian) Select (Mutual of Omaha, National Gaurdian) Standard Class 1 (Substandard) (25% premium rate up Mutual of Omaha) Class 2 (Substandard) (25% premium rate up Mutual of Omaha)

Spouse/Partner Benefit Amount *

Spouse/Partner Benefit Period (Duration) * 2 years3 years4 years5 years6 yearsLifetime (National Guardian Life)

Spouse/Partner HHC * 100%75%50%None

Spouse/Partner Elimination Period * 306090180365

Spouse/Partner Compound Inflation Protection * None2%3%4%5%

Spouse/Partner Riders * NoneHHC 1st day waiver of EPReturn of PremiumRestoration of BenefitsWaiver of PremiumNon-Forfeiture

Date & Time Needed

Comments Any additional information you feel necessary to create the quote.

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