Nationwide YourLife CareMatters®

LIFE Brokerage

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Producer Information

First Name

Last Name

Email

Phone

Insured Information

First Name

Last Name

Date of Birth

Enter Age

January February March April May June July August September October November December

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

*

Gender

Male Female *

State

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshal Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming *

Tobacco User Married/Domestic Partnership

Quote Criteria

Calculation Type

Monthly Benefit Total Benefit Daily Amount Premium Specified Amount *

Desired Premium

*

Payment Schedule

Single Premium 5-Pay 10-Pay Pay to Age 65 Pay to Age 100 *

Payment Frequency

Annual *

Benefit Duration

6 Years

*

Lump Sum Premium

Refund of Premium Option

Maximum LTC Benefit

*

Inflation Protection

Select At Least 1

*

1035 Exchange?

No Yes

Exchange Amount

Existing Contract MEC?

No Yes

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