**  COVERAGE TYPE  **
                                             Joint  Individual

                                             ** PRIMARY APPLICANT  **
                    First: Last: Date of Birth: Male  Female 
                                            Do you smoke?  Yes  No
                    Medical Conditions: 
                    Prescription Drugs: 

                                                  **  SPOUSE  **
                    First: Last: Date of Birth: Male  Female 
                                        Does your spouse smoke?  Yes  No
                    Medical Conditions: 
                    Prescription Drugs: 

                    Email Address:      
                    Phone Number:       
                    Street Address:     
                    City:                State: 
                    Zip Code:           

                                           *** DISCRIPTION OF COVERAGE ***

                    Daily Facility Coverage Amount:  Home Health Care %: 

                    Benefit Period: 3 Years     5 Years   Life Time     Other

                    Elimination Period: Zero Days     30 Days   60 Days     90 Days     Other

                    Method of Payment: Annual     Semi-Annual   Quarterly     Other

                    Payment Options: 10 Year Pay     20 Years Pay  Life Time Pay     Other

                    Inflation Coverage: None     5% Simple  5% Compound     Other

                    Return of Premium (Non forfeiture): None     Shortened   Full   

                    Comments: