NGL Long Term Care

Contract State:

Coverage Type:

Single

Joint

Primary Insured:

Date of Birth

Age

Date of Birth:

Gender:

Male

Female

Rate Class:

Secondary Insured:

Date of Birth

Age

Date of Birth:

Gender:

Male

Female

Rate Class:

Association:

Yes

No

Partner Discount (one Applicant):

Yes

No

Allowed age range is

Primary Insured Benefit Amount:

Secondary Insured Benefit Amount:

Shared Benefit Amount:

Premium Amount:

The step-rated inflation option will cause the premium to increase by $ annually.

AT POLICY ISSUE

Premium Paid

$0.00

LTC Benefits

$0.00

ROP at Death

$0.00

Surrender Value

$0.00

Benefits at policy issue payable up to $ per month.

AT AGE 85*

Premium Paid

$0.00

LTC Benefits

$0.00

ROP at Death

$0.00

Surrender Value

$0.00

Benefits at age 85 payable up to per month.

Change

Base PLAN OPTIONS

Solve For:

Per Month Benefit

Premium

Per Month Benefit:

Benefit Period:

Inflation Protection:

Shared Benefit Amount:

Yes

No

Elimination Period:

PREMIUM OPTIONS

Premium Duration:

Premium Mode:

OTHER OPTIONS

First Day HCCS Benefit:

Yes

No

Shortened Benefit Period Nonforfeiture:

Yes

No

The Shortened Benefit Period Nonforfeiture Rider is not available with a Return of Premium Rider.
The combination of "10-Year Premium" and "Shortened Benefit Period Nonforfeiture" is not allowed.

*assumes a claim at age 85 at which time premiums would be waived - premiums are calculated from policy issue through age 84
This is only a quote. Actual premiums may vary by up to one dollar for every thousand dollars of premium. This quote is a general description of benefits selected and is not a policy contract. It is not to be used without the Outline of Coverage for the state listed above. Please refer to the policy for the actual premiums. Product underwritten by NGL Insurance Company, Madison, Wis.

AGENT INFORMATION

First Name:

Last Name:

Agent’s Email Address:

Agent's Phone:

Primary Applicant INFORMATION

First Name:

Last Name:

Secondary Applicant INFORMATION

First Name:

Last Name:

Association/Worksite Group INFORMATION

Name: