{"id":117,"date":"2014-07-01T12:08:27","date_gmt":"2014-07-01T12:08:27","guid":{"rendered":"http:\/\/www.ocbis.com\/?page_id=117"},"modified":"2014-07-11T05:24:55","modified_gmt":"2014-07-11T05:24:55","slug":"long-term-care-quote-request","status":"publish","type":"page","link":"https:\/\/www.ocbis.com\/index.php\/long-term-care-quote-request\/","title":{"rendered":"Long Term Care Quote Request"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f230-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/117#wpcf7-f230-o1\" method=\"post\" class=\"wpcf7-form\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"230\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.0.5\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f230-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<\/div>\n<table  class=\"LTC-form-table\">\n<tr>\n<td colspan=\"4\" class=\"agent-info\">\n<h3 class=\"LTC-heading\">Agent Information<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td>Agent Name\/Branch:<\/td>\n<td>Delivery Method:<\/td>\n<td>Needed By:<\/td>\n<td>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap NeededBy\"><select name=\"NeededBy\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yesterday\">Yesterday<\/option><option value=\"ASAP\">ASAP<\/option><option value=\"Tomorrow\">Tomorrow<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<tr>\n<td><span class=\"wpcf7-form-control-wrap AgentNameBranch\"><input type=\"text\" name=\"AgentNameBranch\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required agent-field\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Agent Name\/Branch\" \/><\/span><\/td>\n<td>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap DeliveryMethod\"><select name=\"DeliveryMethod\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"E-Mail\">E-Mail<\/option><option value=\"Fax\">Fax<\/option><option value=\"Mail\">Mail<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>LTC Company:<\/td>\n<td>\n               <span class=\"wpcf7-form-control-wrap LTCCompany\"><select name=\"LTCCompany\" class=\"wpcf7-form-control wpcf7-select select-box-ltc select-col\" aria-invalid=\"false\"><option value=\"Met\">Met<\/option><option value=\"Hancock\">Hancock<\/option><option value=\"Pru\">Pru<\/option><option value=\"GE\">GE<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n<\/td>\n<\/tr>\n<tr>\n<td><span class=\"wpcf7-form-control-wrap email\"><input type=\"email\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email agent-field\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email *\" \/><\/span><\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap need\"><select name=\"need\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Full Proposal\">Full Proposal<\/option><option value=\"Premiums Only\">Premiums Only<\/option><\/select><\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td><span class=\"wpcf7-form-control-wrap phone\"><input type=\"tel\" name=\"phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel agent-field\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone *\" \/><\/span><\/td>\n<td>&nbsp;<\/td>\n<\/tr>\n<tr>\n<td><span class=\"wpcf7-form-control-wrap FaxNumber\"><input type=\"tel\" name=\"FaxNumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel agent-field\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"FAX *\" \/><\/span><\/td>\n<td>&nbsp;<\/td>\n<\/tr>\n<\/table>\n<div class=\"clear\"><\/div>\n<p><br\/><\/p>\n<table class=\"LTC-form-table\">\n<tr>\n<td colspan=\"8\" class=\"agent-info\">\n<h4 class=\"LTC-heading\">Proposed Insured #1<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td>Client Name:<\/td>\n<td><span class=\"wpcf7-form-control-wrap ClientName1\"><input type=\"text\" name=\"ClientName1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Client Name\" \/><\/span><\/td>\n<td>Date of Birth:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DOB\"><input type=\"text\" name=\"DOB\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" id=\"datepicker1\" aria-required=\"true\" \/> <\/span> <\/td>\n<td>Smoking Status:<\/td>\n<td>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap SmokingStatus\"><select name=\"SmokingStatus\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"NS\">NS<\/option><option value=\"SM\">SM<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Sex: <\/td>\n<td>\n\t\t\t\t<span class=\"wpcf7-form-control-wrap Sex\"><select name=\"Sex\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<tr>\n<td>Daily Benefit:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DailyBenefit\"><input type=\"text\" name=\"DailyBenefit\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Waiting Period:<\/td>\n<td><span class=\"wpcf7-form-control-wrap WaitingPeriod\"><select name=\"WaitingPeriod\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"30\">30<\/option><option value=\"60\">60<\/option><option value=\"90\">90<\/option><option value=\"120\">120<\/option><option value=\"180\">180<\/option><option value=\"360\">360<\/option><\/select><\/span><\/td>\n<td>Benefit Period (Duration):<\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap BenefitPeriodDuration\"><select name=\"BenefitPeriodDuration\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"Lifetime\">Lifetime<\/option><\/select><\/span><\/td>\n<td>Inflation Option:<\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap InflationOption\"><select name=\"InflationOption\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"None\">None<\/option><option value=\"Simple\">Simple<\/option><option value=\"Compound\">Compound<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<tr>\n<td>Underwriting Class:<\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap UnderwritingClass\"><select name=\"UnderwritingClass\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Preferred\">Preferred<\/option><option value=\"Standard\">Standard<\/option><option value=\"Rated\">Rated<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Home Health Care:<\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap HomeHealthCare\"><select name=\"HomeHealthCare\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"None\">None<\/option><option value=\"50%\">50%<\/option><option value=\"75%\">75%<\/option><option value=\"100%\">100%<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Type Of Plan:<\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap TypeOfPlan\"><select name=\"TypeOfPlan\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"TQ\">TQ<\/option><option value=\"Non-TQ\">Non-TQ<\/option><option value=\"Partnership\">Partnership<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<tr>\n<td class=\"sub-table-heading\" colspan=\"8\"><strong>Medications being taken or known health history(high blood pressure, cancer, etc\u2026) <\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"8\">\n\t\t\t\t<span class=\"wpcf7-form-control-wrap Medications\"><textarea name=\"Medications\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea ltc-textarea\" aria-invalid=\"false\"><\/textarea><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<\/table>\n<table class=\"LTC-form-table\">\n<tr>\n<td colspan=\"8\" class=\"agent-info\">\n<h4 class=\"LTC-heading\">\tProposed Insured #2<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td>Client Name:<\/td>\n<td><span class=\"wpcf7-form-control-wrap ClientName2\"><input type=\"text\" name=\"ClientName2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text full-inputfield\" aria-invalid=\"false\" placeholder=\"Client Name\" \/><\/span><\/td>\n<td>Date of Birth:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DOB2\"><input type=\"text\" name=\"DOB2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker9\" \/> <\/span> <\/td>\n<td>Smoking Status:<\/td>\n<td>\n\t\t\t\t\t<span class=\"wpcf7-form-control-wrap SmokingStatus2\"><select name=\"SmokingStatus2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"NS\">NS<\/option><option value=\"SM\">SM<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Sex: <\/td>\n<td>\n\t\t\t\t\t<span class=\"wpcf7-form-control-wrap Sex2\"><select name=\"Sex2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<tr>\n<td>Daily Benefit:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DailyBenefit2\"><input type=\"text\" name=\"DailyBenefit2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Waiting Period:<\/td>\n<td><span class=\"wpcf7-form-control-wrap WaitingPeriod2\"><select name=\"WaitingPeriod2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"30\">30<\/option><option value=\"60\">60<\/option><option value=\"90\">90<\/option><option value=\"120\">120<\/option><option value=\"180\">180<\/option><option value=\"360\">360<\/option><\/select><\/span><\/td>\n<td>Benefit Period (Duration):<\/td>\n<td><span class=\"wpcf7-form-control-wrap BenefitPeriodDuration2\"><select name=\"BenefitPeriodDuration2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"Lifetime\">Lifetime<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Inflation Option:<\/td>\n<td><span class=\"wpcf7-form-control-wrap InflationOption2\"><select name=\"InflationOption2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"None\">None<\/option><option value=\"Simple\">Simple<\/option><option value=\"Compound\">Compound<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<tr>\n<td>Underwriting Class:<\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap UnderwritingClass2\"><select name=\"UnderwritingClass2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Preferred\">Preferred<\/option><option value=\"Standard\">Standard<\/option><option value=\"Rated\">Rated<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Home Health Care:<\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap HomeHealthCare2\"><select name=\"HomeHealthCare2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"None\">None<\/option><option value=\"50%\">50%<\/option><option value=\"75%\">75%<\/option><option value=\"100%\">100%<\/option><\/select><\/span>\n<\/td>\n<td>Type Of Plan:<\/td>\n<td>  <span class=\"wpcf7-form-control-wrap TypeOfPlan2\"><select name=\"TypeOfPlan2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"TQ\">TQ<\/option><option value=\"Non-TQ\">Non-TQ<\/option><option value=\"Partnership\">Partnership<\/option><\/select><\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"sub-table-heading\" colspan=\"8\"><strong>Medications being taken or known health history(high blood pressure, cancer, etc\u2026) <\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"8\">\n\t\t\t\t<span class=\"wpcf7-form-control-wrap Medications2\"><textarea name=\"Medications2\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea ltc-textarea\" aria-invalid=\"false\"><\/textarea><\/span>\n\t\t\t\t<\/td>\n<\/tr>\n<\/table>\n<div class=\"clear\"><\/div>\n<div class=\"login-btn-div2\">\n<input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control wpcf7-submit login-btn\" \/><input type=\"reset\" class=\"login-btn\" value=\"Reset\"><\/p><\/div>\n<div class=\"wpcf7-response-output wpcf7-display-none\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"page-templates\/form-template.php","meta":{"footnotes":""},"class_list":["post-117","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/117"}],"collection":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/comments?post=117"}],"version-history":[{"count":4,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/117\/revisions"}],"predecessor-version":[{"id":231,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/117\/revisions\/231"}],"wp:attachment":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/media?parent=117"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}