All Aboard Benefits
6333 E. Mockingbird Lane, #147-901, Dallas , TX 75214
Phone: (214) 821-6677    FAX: (214) 821-6676   
email: customerservice@allaboardbenefits.net
URL: http://www.allaboardbenefits.net

Request for Long Term Care Quote Form

Print this form, complete it and fax or mail it to All Aboard Benefits (AAB) at the address above. One of our agents will contact you within two working days of receipt.

 DATE: _________________

CLIENT NAME: _________________ AGE OR DOB: ________ SEX: ___

SPOUSE NAME: ________________ AGE OR DOB: ________ SEX: ___

 STATE: _______ QUALIFIED OR NON-QUALIFIED: ________________

 DAILY BENEFIT: _______ ELIM. PERIOD (0, 30, 60, 90 days): ________

BENEFIT PERIOD (2, 3, 4, 5, 6 yrs, Lifetime): ________________

 INFLATION PROTECTION: ____________
(NONE, SIMPLE, COMPOUND)

 ASSISTED LIVING FACILITY: (50%, 75%, 100%): _____________

HOME HEALTH CARE (50%, 75%, 100%): ______________

 MODAL FACTOR: ______________
(MONTHLY PAC, QUARTERLY, SEMI-ANNUAL, ANNUAL)

 DISCOUNTS: _______ SPOUSE ________ GROUP

                        ________ OTHER (SPECIFY) _________________

 OTHER BENEFITS: _______________________________________

 LIST CURRENT MEDICATIONS: ____________________________

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SPECIAL INSTRUCTIONS & DATE NEEDED: ___________________

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Copyright © 2004-2008 All Aboard Benefits   All rights reserved.
Last revised: January 23, 2008