The Palmer Agency

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Quotes: Term | Annuity | Health | Permanent | Long Term Care

Client First Name:		DOB/Age:
Client Last Name:

Spouse/Partner First Name		DOB/Age:
Spouse/Partner Last Name:

Married? Yes No Live-in Partner? Yes No Number of Years Lived Together:

State where client(s) reside: (LTC application MUST be taken in client?s state of residence)

Please check up to 3 carriers OR have The Palmer Agency make a recommendation
*All carriers may not be available in all states
Genworth John Hancock Met Life Mutual of Omaha Prudential Palmer Agency Recommendation

	Client	Spouse/Partner	Check One for Each Option
NH Daily/Monthly Benefit			Inflation: Compound Simple GPO None
Benefit Period (Years)			Payment Options: Lifetime 10-Pay Paid Up at 65
Elimination Period			Optional Benefits Requested:

**All options may not be available in all states

	Client	Spouse/Partner
Tobacco use last 5 years	Yes No Quit Date:	Yes No Quit Date:
Height & Weight
Health Conditions and Diagnosis Dates
Medications - dosage, date started, reason for taking
Hospitalizations in last 5 years - reasons & dates
If medical history unknown, quote preferred or standard?	Preferred Standard	Preferred Standard

*Producer's First Name:		*Producer's Last Name:
Date and Time Needed:		*Agent's Resident State:
*Phone Number:		Send brochure with quote? Yes No
*Email:		Send application with quote? Yes No
Fax Number:		Send quote by: Email Fax

* - Denotes Required Field

THE PALMER AGENCY © 2008 Privacy Policy | Terms Of Use
1849 Clairmont Road
Decatur, Georgia 30033
Local: 404.321.1212 | Toll Free: 1.800.241.3203 | Fax: 404.634.3990