**  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: