800-537-5568
Name *
Fax
Phone *
State State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Email *
Please send quote by Email Fax *
Date of Birth *
Tobacco Usage Yes No *
If YES, what type
Underwriting Class Preferred Select Standard Substandard (by underwriter offer only) *
Daily Benefit *
Benefit Period: 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years Lifetime (Best Option) *
Elimination Period 0 days 20 days 30 days 45 days 90 days 100 days *
Pay Type Lifetime 10-Pay 20-pay To Age 65 *
Pay Mode Annual Semi-Annual Quarterly Monthly Pac *
Benefit Increase Rider
Compound 3% 4% 5% Simple (5%)
Nonforfeiture Benefit Full (Full return of premium) Shortened
Shared Care Restoration of Benefits Return of Premium
Please type the text displayed in the following image: