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The information on this page may not apply to residents of all states. Product availability may vary.

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Burling Insurance Group Long Term Care can suggest a long term care (LTC) insurance plan that’s right for you. We will work with you to choose insurance coverage based on your care preferences, the benefits you would like to receive and the amount of coverage you can afford.

This is not the application. Answering the questions on this form will not result in a determination of your eligibility for coverage.

Once you have decided on a long term care insurance plan and insurance company, an LTC insurance specialist or a licensed LTC insurance agent will mail or fax your application to you. For help on a question you do not understand, please feel free to call us at 1-877-977-0125.

Part 1 of 2

1. Most financial advisors suggest that you should not spend more than 5-7% of your annual income on long term care. Please consider your annual income. Is it:
(You need not answer this question. This is for your own information. You may also want to consider your savings.)
Under $20,000
$20,000 - $30,000
$30,000 - $50,000
$50,000 - $100,000
Over $100,000

2. Which type of coverage would you prefer?
(Additional premium may be required.)
Nursing Home Care Only
Home and Community Care Only
Comprehensive Nursing Home Care with Home and Community Care
I’m Not Sure

3. With a longer waiting period, your annual premium will be less expensive. However, your out of pocket expenses will increase. According to Genworth Financial’s 2006 Cost of Care Survey, the average daily cost for a private nursing home room is $194.28. With this in mind, how long can you afford to pay out of pocket before benefits are paid?
(Additional premium may be required.)
0 days
30 days
60 days
90 days
180 days
365 days
I’m Not Sure

4. The average stay in a nursing home is 2.4 years (MetLife marketing survey, 2004). However, this does not include the home health care that you may receive prior to entering a nursing home. How long would you like to have your benefits last?
(Additional premium may be required.)
2/3 years
5/6 years
10 years
Lifetime (Unlimited Coverage)
I’m Not Sure

5. If you answer yes to any of the following questions, you may want to consider a longer benefit period.

Do you live alone?	Yes No
Is there a history of longevity in your family?	Yes No
Is there a history of chronic illness or Alzheimer’s disease?	Yes No
Are you a woman?	Yes No
Do you own your own business?	Yes No

6. Were there any riders that you were interested in?
(Additional premium may be required.)
Inflation Riders
Informal Caregiving
Nonforfeiture Benefit Riders (reduced benefits)
Other

7. Are you interested in learning more about a specific insurance carrier? Please indicate here:

Part 2 of 2

*Full Name:

*Are you married?
Yes
No

Spouse’s Name:

*Address:

*City, State, Zip:

*Phone Number:

*E-mail Address:

*Date of Birth:
(mm/dd/yyyy)

Spouse’s Date of Birth:
(mm/dd/yyyy)

*Your Occupation:

(If retired, please list your last occupation and year retired.)

Spouse’s Occupation:

(If retired, please list spouse’s last occupation and year retired.)

Additional Comments or Questions: