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HKFS Long-Term Care Quote Request

Fax Request to Insurance Dept. at (563) 582-1040 or email to e-quotes@hkfs.com Honkamp Krueger Financial Services, Inc.
3390 Asbury Road, Dubuque, IA 52002 Phone: (563) 582-2855


Information

Client Information
Business Owner Y / N (If Yes, C or S Corp)
  • YesNo

Medical/Lifestyle Information

Does the client live on his/her own?
  • YesNo
Does the client drive?
  • YesNo
Is the client currently working?
  • YesNo
Any hospital stays in the last five years?
  • YesNo

Does the client live on his/her own?
  • YesNo
Does the client drive?
  • YesNo
Is the client currently working?
  • YesNo
Any hospital stays in the last five years?
  • YesNo

Known health issues or prescribed medications:

i.e. Cancer, Coronary Disease, HBP, Osteoporosis, Stroke, etc.


Request Coverage and Benefits
Shared Care
  • YesNo
Home Care
  • 100%75%50%
Restoration of Benefits
  • YesNo
Benefit Period in Years*
Return of Premium
  • YesNo
Elimination Period*
Premium Mode
  • ASQM
Inflation Protection
  • NoneSimpleCompound
Long Term Care Rider Definitions

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).

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

Inflation Rider:

Simple 5% Interest or Compound 5% Interest.

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.

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.

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.

Limited Pay Options:

You can pay or pay-up policy 10-20 years, to age 65 or with a single premium.

Restoration of Benefits:

Restore benefits if more than 180 days separate covered charges. This is with benefit period other than unlimited (life).