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Disability Quote Request
Submission Routing
Please Enter Your Location Information Below:
City Name:
City Zip Code:
Your Location:
(Required)
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Texas
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Washington
West Virginia
Wisconsin
Wyoming
Producer Information
Name:
Phone:
(please include your area code.)
Fax:
(please include your area code.)
Email:
(Required)
All proposals and product information will be sent to you by email unless we are instructed otherwise.
Client Information
Name:
Birth Date:
Month
Day
Year
Sex:
Male
Female
State of Residence:
Marital Status:
Single
Married
Divorced
Widowed
Domestic Partnership
Tobacco or Nicotine Use:
Yes
No
Type of Tobacco or Nicotine:
If quit, last used:
Details:
Medical Information
Current Height:
Current Weight:
Has there been any weight change of more than 10 lbs in the last year?
Yes
No
If yes, details:
Current Medications & Dosages
In the last ten years, has your client been treated for or been diagnosed as having: (please check all that apply)
High blood pressure, chest pain, heart murmur or disorder of the heart or circulatory system
Diabetes, cancer, tumor, disorder of the thyroid, pancreas or lymph nodes or disorder of the glands, bone, blood or skin
Complication of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system
Hernia, Hepatitis or disorder of the liver, gall bladder, appendix, stomach, intestines or rectum
Arthritis, rheumatism, gout or disorder of the joints, limbs or muscles
Disorder or condition of the back, neck or spine including 'wellness' chiropractic visits
Tuberculosis, Allergy, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system
Epilepsy, stroke, dizziness, headache, paralysis or disorder of the brain or spinal cord
Disorder of the eyes, ears, nose or throat
Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorder or counseling for personal or work issues
Chronic Fatigue Syndrome, Epstein Barr virus or Lyme disease
Treatment for drug or alcohol abuse or use of any controlled substance
Has your client been rated, declined or offered modified coverage from any life or health insurance carrier
In the last 5 years has your client visited a physician, clinic or medical practitioner for treatment of any disease or disorder or been advised to begin any treatment program?
Details
Please enter details for any box checked
Employment Information
Occupation:
Specific Job Duties:
Length of Employment
Work out of Home?
Yes
No
If yes, details:
Does the prospect own his/her own business?
Yes
No
If yes, details including the percentage of ownership, how long the prospect has owned the business, number of employees, etc.? This is IMPORTANT for obtaining the best occupation class possible:
BOE Coverage
Would you like a proposal for Business Overhead Expense coverage?
Yes
No
If yes, what is the total monthly overhead expense for the business?
What is the proposed insured's percentage of ownership?
What form of business?
C Corp
S Corp
Proprietorship
Partnership
LLC
Buy/Sell Coverage
Would you like a proposal for Disability Buy Sell coverage?
Yes
No
If yes, what is the total value of the business?
Buy Sell Trigger Point
12 Months
18 Months
24 Months
Lump Sum:
Yes
No
Monthly Funding
Yes
No
TAXABILITY OF PREMIUM/BENEFIT INFORMATION:
(Income after business expenses but before taxes)
Salary: Current YTD:
Last Tax Year:
Bonus: Current YTD:
Last Tax Year:
Commission: Current YTD:
Last Tax Year:
Do you want to see a retirement plan protection product proposal?
Yes
No
If no, Explain:
Total Retirement Plan Contributions
Type of Retirement Plan
Has the Bonus or Commission been consistent for the last 3 years?
Yes
No
OTHER DISABILITY COVERAGE INFORMATION:
Does the prospect have ANY other disability benefits (including Group STD or LTD)?
Yes
No
If yes, please provide details, including the tax-ability of the benefits when received, benefit maximums, elimination period, etc.
Illustration
DESIRED ILLUSTRATION INFORMATION: (Not all carriers provide all benefits or options or make them available to all risk classes - we will attempt to match your quote as closely as possible to your request)
Short Term Disability
Elimination Period:
14 Days
30 Days
60 Days
90 Days
Benefit Period:
3 Months
6 Months
12 Months
24 Months
Product Requested:
Accident Only
Accident & Sickness
Long Term Disability
Elimination Period:
30 Days
60 Days
90 Days
180 Days
365 Days
730 Days
Benefit Period:
6 Months
12 Months
2 Years
5 Years
10 Years
To Age 65
To Age 70
Lifetime
Product Requested:
2 Years
5 Years
To Age 65
To Age 70
Life Time
Optional Provisions:
Specialty Own Occupation
Transitional Your Occupation
Residual (24 Months)
Residual (To Age 65, To Age 67 or To Age 70)
COLA (Minimum)
COLA (Maximum)
Catastrophic/ADL Rider
Future Purchase Option(s)
Group Replacement/Supplemental Rider?
Social Insurance Offset Rider
Partial Disability
Return of Premium
Treatment of Injuries or Hospital Benefits
Long Term Care Guaranteed Purchase Rider
Retirement Protection Benefits
(Not all riders are available on all products)
Special Instructions:
Additional Information
Carrier Selection
Would you like us to recommend a carrier we feel provides the best value?
Yes
No
(If you select NO, multiple quotes will be provided)
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