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Name*

First Last

Classification*

Company Name*

Email*

Product or Service Sought?*

Please fill out separate requests for each product or service sought.

Please specify the type of case: Married Couple or Single Individual?*

Married Couple
Single Individual

Who is the proposed owner / annuitant?*

Institutionalized Individual
Community Spouse
Other

What product are you seeking?*

Level Pay Annuity
Balloon Style Annuity

What is the owner/annuitant's first and last name?*

First Last

What is the proposed owner/annuitant's first and last name?*

First Last

What is owner of the annuity's name?*

First Last

What is the proposed owner / annuitant's date of birth?*

What is the State of Residence?*

Do you know the desired annuity term and investment amount?*

Desired Annuity Term for Medicaid Compliant Annuity*

Equal to Insured's Medicaid Life Expectancy
Other

Desired Monthly Payout Structure

Premium Amount or Desired Monthly Payout of MCA*

Enter the amount*

Are the funds for the MCA tax-qualified or non-qualified*

Tax-Qualified
Non-Qualified
I'm not sure

What is the claimant's gross monthly income?

What are the total countable assets?*

What are the total countable assets as of today?*

What is the institutionalized spouse's gross monthly income?*

What is the spouse's gross monthly income?*

What are the total countable assets as of the snapshot date?*

What is the community spouse's gross monthly income?*

What are the total countable assets as of today?*

What is the individual's gross monthly income?*

What is the private pay rate of the facility?*

What are the Veteran's total Unreimbursed Medical Expenses?*

What are the claimant's total Unreimbursed Medical Expenses?*

What are the spouse's total Unreimbursed Medical Expenses?

What is the desired face value of the Whole Life Insurance Policy?*

What is the desired face value of the Funeral Expense Trust?*

Are the Refusal Letters for an existing annuity contract?*

Yes
No

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