The Florida Bar Member Benefits Provided by BPC Financial

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Long Term Care Quote Request

The only contact will be from a TFB Member Benefits Long Term Care advisor who is a licensed agent in your state. This contact will be to verify your information so that you receive an accurate, cost-comparison quote and appropriate decision assistance support.

FL Bar Member #:
Phone Number:
FaxNumber:
E-mail Address:
Mailing Address:
City:
State:
Zip:
How did you hear about us?:

Person #1
Name:
Date of Birth:
Gender:
Tobacco:
Relation to Bar Member:
Height/Weight:	ft. inches lbs.
Have you been hospitalized in the past 5 years? If so, for what duration and condition?
Are you currently taking any prescription medications? If yes, Name, Dosage, How long and for what condition(s).
Do you have any pending surgery? If yes, provide details.
Do you currently have or have you ever had in the past any serious medical problems such as: Diabetes, Cancer, Heart Problems, Stroke, or Osteoporosis? If so, need to know details such as when, treatment, and current status.
Any physical limitations? Support devices? Type? Reason for use? Duration?
Do you have any medical conditions or problems not already metioned above?
Financial Questions As important as long term care insurance is, it is not for everyone. These next two questions will help us determine if financially, purchasing long term care insurance makes sense for your situation or is there a better way for you to address this issue. We have intentionally made these questions very broad, however if you are uncomfortable answering them just leave them blank and we can discuss them when we speak.
With the cost of care averaging in excess of $70,000 per year, if you had to use your own assets to pay for your care, (do not include the value of your home) approximately how long could you afford to pay for your own care?
After paying all of your bills each month, approximately how much "left over" or descrectionary income do you have?
Important Disclaimer: This is NOT an application for insurance. This is simply an information gathering tool by which we can generate accurate premium quotations and make recommendations for long term care insurance. No insurance will go into effect until after you complete an actual application to an insurer, pay your first premium, and are approved by the insurer.
Person #2
Name:
Date of Birth:
Gender:
Tobacco:
Relation to Bar Member:
Height/Weight:	ft. inches - lbs.
Have you been hospitalized in the past 5 years? If so, for what duration and condition?
Are you currently taking any prescription medications? If yes, Name, Dosage, How long and for what condition(s).
Do you have any pending surgery? If yes, provide details.
Do you currently have or have you ever had in the past any serious medical problems such as: Diabetes, Cancer, Heart Problems, Stroke, or Osteoporosis? If so, need to know details such as when, treatment, and current status.
Any physical limitations? Support devices? Type? Reason for use? Duration?
Do you have any medical conditions or problems not already metioned above?
Financial Questions As important as long term care insurance is, it is not for everyone. These next two questions will help us determine if financially, purchasing long term care insurance makes sense for your situation or is there a better way for you to address this issue. We have intentionally made these questions very broad, however if you are uncomfortable answering them just leave them blank and we can discuss them when we speak.
With the cost of care averaging in excess of $70,000 per year, if you had to use your own assets to pay for your care, (do not include the value of your home) approximately how long could you afford to pay for your own care?
After paying all of your bills each month, approximately how much "left over" or descrectionary income do you have?
Important Disclaimer: This is NOT an application for insurance. This is simply an information gathering tool by which we can generate accurate premium quotations and make recommendations for long term care insurance. No insurance will go into effect until after you complete an actual application to an insurer, pay your first premium, and are approved by the insurer.