Seniors Coalition Insurance Benefits Program

Program Manager, Michael L. Crifasi, CFP

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Long Term Care Request

Please fill in the information requested so that we can email you a proposal specific to your state. The required fields are indicated in bold.

Member's Information

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Member Name:
Member E-mail Address:

Insured's Information

Name:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone 1:
Phone 2:
FAX:
E-mail Address:
Height:
Weight:
Are you a Licensed Insurance Agent?
Medical History
Have You Ever Used Tobacco?
Date of Last Use:
List all health conditions, dates, and medications with dosage.
Spouse Information
Do you want joint coverage? If "No" skip to the Coverage Information section.
Name:
Date of Birth:
E-mail Address:
Height:
Weight:
Has Your Spouse Ever Used Tobacco?
Date of Last Use:
List all spouse's health conditions, dates, and medications with dosage.
Coverage Information Learn the cost of care in your city by reading this article. Daily Benefit Amount Nursing home dollar benefit desired ($) per day ($50 to $500 in increments of $10) Assisted care facility as a % of Nursing Home Benefit Level of home care as a % of Nursing Home Benefit Is protection for Long Term Care expenses outside the US essential? If "Yes", what country How many years of benefit do you need? We recommend lifetime coverage for disaster protection. Less than lifetime protection is inadequate and should only be used if you feel the cost of lifetime coverage is prohibitive. How many days elimination before you want benefits to start? We recommend 90 days elimination for disaster protection. If your care qualifies for medicare benefits, the policy can not pay any benefits until the medicare coverage period of 100 days is exhausted. Do you want your premium waived if you are in Home Care? This is a nice option to have if you choose a lifetime payment schedule. We don't recommend it with the 10-Pay option. What type of inflation protection do you want? We recommend the compound inflation protection rider if your life expectancy is over 20 years. The Simple inflation rider may be adequate if your life expectancy is less than 25 years and the cost is a critical factor. A $100/day benefit will grow in 20 years to $265 Compound vs $200 simple; in 30 years to $432 compound vs $250 simple; and, in 40 yrs to $704 compound vs $300 simple. Preimum Payment Options: