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HKFS Long-Term Care Quote Request
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Fax Request to Insurance Dept. at (563) 582-1040 Or email to e-quotes @hkfs.com
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Honkamp Krueger Financial Services, Inc. 2355 J.F.K. Road, Dubuque, IA 52002-2835
Phone: (563) 582-2855
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Information
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CPA’s Name *
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CPA’s Phone # *
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Agent Fax # *
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Agent Email Address *
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Financial Advisor *
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Client Information
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Client’s Name *
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Spouse’s Name
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DOB *
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Smoker *
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DOB
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Smoker
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Height
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Weight
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Height
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Weight
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State policy will be written
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Business Owner Y / N (If Yes, C or S Corp)
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Medical/Lifestyle Information
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Client
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Spouse
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Does the client live on his/her own?
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Does the client live on his/her own?
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Does the client drive?
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Does the client drive?
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Is the client currently working?
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Is the client currently working?
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Any hospital stays in the last five years?
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Any hospital stays in the last five years?
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Known health issues or prescribed medications: (i.e. Cancer, Coronary Disease, HBP,
Osteoporosis, Stroke, etc.
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Request Coverage and Benefits
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Nursing Facility Daily Benefit *
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Shared Care
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Home Care
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Restoration of Benefits
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Benefit Period in Years
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Return of Premium
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Elimination Period
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Premium Mode
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Inflation Protection
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Long Term Care Rider Definitions
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For the payment of an additional premium, we will waive premium payments if you
are receiving benefits under your policy, other than for Respite Care, Home Modification,
Therapeutic Device, Caregiver Training and Medical Alert System (if the option you
selected included those overages).
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Non-Forfeiture Rider: For the payment of an additional premium, this rider
provides that if your policy lapses for non-payment of premium after it has been
in force for at least 5 years, we will continue coverage at a reduced level under
your policy.
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Inflation Rider: Simple 5% Interest or Compound 5% Interest.
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Simple provides for an automatic annual increase of your maximum benefit
amounts on each anniversary of your rider effective date. Your maximum benefit amounts
will be increased each year by an amount equal to 5% of your original maximum benefit
amounts each year.
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Compound provides for an automatic annual increase of your maximum benefit
amounts on each anniversary of your rider effective date. Your maximum benefit amounts
will be increased each year by an amount equal to 5% of your previous year’s maximum
benefit amounts. This means that your maximum benefit amounts will increase by increasing
amounts each year.
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Survivorship Benefit: For payment of an additional premium, this rider provides
that if you and your spouse each purchased a long term care insurance policy, your
policy will become paid-up on the later of: (1) the date of your spouse’s death;
(2) the 10th anniversary of your policy effective date. Paid-up means that no further
premiums will be payable on your policy.
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Return of Premium Rider: For payment of an additional premium, this rider
provides that if you die while this policy is in force we will return to your beneficiary,
if any, or your estate, all the premium you paid for this policy and any attached
riders, reduced by the sum of incurred claims.
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Limited Pay Options: You can pay or pay-up policy 10-20 years, to age 65
or with a single premium.
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Restoration of Benefits: Restore benefits if more than 180 days separate
covered charges. This is with benefit period other than unlimited (life).
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