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To receive your FREE LONG TERM CARE REPORT with the most competitive immediate quotations, please complete the short form that follows. If you prefer, you can always call MacMillan Financial at (908) 236-7500
 

 
Section 1 - Applicant Information
Applicant's Name: 
Applicant's Date of Birth: 
 ex. 01/01/2005
Applicant's State of Residence: 
Applicant's Email Address: 
Applicant's Sex: 
  Male  Female
Medications taken on a  
regular basis:
 
Quote a preferred class
on the applicant?
 
Yes No
Section 2 - Joint Applicant Information
Joint Applicant's Name: 
Joint Applicant's Date of Birth: 
Joint Applicant's State of Residence: 
Joint Applicant's Email Address: 
Joint Applicant's Sex: 
Male Female
Medications taken on a  
regular basis:
 
Quote a preferred class  
on the Joint applicant?
 
Yes No
Section 3 - Quote Information
State in which this application  
will be signed:
 
Company(s) requested: 
Benefit Amount: 
$

Daily Monthly
Elimination Period: 
Benefit Period: 
Inflation: 
Quote Shared Care? 
Yes No
HHC Amount: 
0%
50%
75%
100%
HHC Indemnity? 
Yes No
HHC Waiver of Elimination Period? 
Yes No
Payment Options: 
Annual
Semi-Annual
Quarterly
Monthly
Pre-Payment Options: 
10 Pay
Single Pay
Pay to 65
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