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Medicaid Compliant Annuity

Attorney or Advisor’s Contact Information
Name*
First Last
Company*
Address
Street Address City State ZIP Code
Phone
Email*
Facsimile
Client Data
Type of Case*
Client Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM
DD
YYYY
State*
Term of Annuity (Months)
or Medicaid Life Expectancy?
- Life Expectancy
Premium Amount
Qualified Money (IRA, 401K, etc.)?
- Yes
- No
County the Medicaid applicant will be applying for benefits
Has the applicant applied for Medicaid in the past?*
- Yes
- No
Please describe the number of times an application was submitted, if they were approved, and approximately how long the applicant received benefits:*
Month of Medicaid Eligibility (if applicable)
Total Countable Resources (if applicable)
Monthly Income Amount (if applicable)
Monthly Nursing Home Cost (if applicable)
Is the community spouse or any of the responsible parties interested in learning more about long-term care insurance?
- Yes
- No
Additional Comments
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