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First Name*
Last Name*
Address*
Street Address Address Line 2 City State ZIP Code
Gender
Date of Birth *
MM-DD-YY
Height
Weight
Smoking Status
If you have quit smoking, for how long?
Partner/Martial Status
Partner/Spouse Applying
Partner/Spouse Information
First Name
Last Name
Address
Street Address City State ZIP Code
Gender
Date of Birth *
MM-DD-YY
Height
Weight
Smoking Status
If you have quit smoking, for how long?
Health Considerations
Please list all health considerations experienced in the last five years (i.e. Graves Disease, Hypertension) and the date of last treatment if applicable. Please be as detailed as possible
Client
Partner/Spouse
Current Prescriptions
Please list all current prescriptions (i.e Wellbutrin, 50 mg/day)
Client
Partner/Spouse
Long-Term Care Coverage Options
Daily Benefit*
$10 Increments
Length of Coverage*
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- Unlimited
(Years)
Elimination Period*
- 20/30 Days
- 50/60 Days
- 90/100 Days
- 180 Days
- 365 Days
Inflation Protection Period*
- 3% Compound
- 5% Simple
- 5% Compound
- GPO
- None
Premium Mode*
- Monthly (EFT)
- Quarterly
- Semi-Annually
- Annually
Limited Pay Options*
- Pay To Age 65
- Ten Pay
- Life Pay
Riders
Notes
Agent Information
Life License#*
Name*
First Last
Company Name*
Broker/Dealer
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email
Contact Preference
- Phone
- Fax
- Email

Corporate headquarters | 15373 Innovation Drive, Suite 200, San Diego, CA 92128 | (800) 238-8144 - Contact Us

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For Professional Use Only.
Securities offered through The Leaders Group, Inc. Member FINRA/ SIPC 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303-797-9080
Westland Financial Services Inc. is not affiliated with The Leaders Group, Inc. Westland CA Insurance Lic #: 0785972

Partner/Spouse Information

Health Considerations

Current Prescriptions

Long-Term Care Coverage Options

Agent Information

Corporate headquarters | 15373 Innovation Drive, Suite 200, San Diego, CA 92128 | (800) 238-8144 - Contact Us

Privacy Policy | Terms of Use