Ellebrecht Insurance Agency

Request Information:
Long Term Care and Home Health Care

Please Complete "All Of The Information listed below

Customer Name:	First MI Last
Address	Street City State Zip
Phone Number: (xxx) xxx-xxxx
Email:
Date of Birth:	/ /
Sex:
Height & Weight:	&
Tobacco Use:	Never No Yes
Marital Status :
State of Primary Residence :
Daily Nursing Home Benefit desired :	$
Benefit Period :
Rate Class :
Waiting Period Before Benefits Begin :
Include Compound Inflation Protection?:	Yes (recommended) No
Include Spouse Discount? :	Yes No (Spouse discount applies for most companies when both husband and wife apply for coverage at the same time)
Optional Spouse Information
Name :	First MI Last
Date of Birth:	/ /
Height & Weight:	&
Comments: