Disability Insurance Proposal Request

Disability Insurance Proposal Request Form

Submission Routing

Please Enter Your Location Information Below:

City Name:

City Zip Code:

Your Location (required):

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:

Sex:
MaleFemale

State of Residence:

Marital Status

Tobacco or Nicotine Use:
YesNo

Type of Tobacco or Nicotine:

If quit, last used:

Details:

Medical Information

Current Height

Current Weight

Has there been a weight change of more than 10 lbs in the last year?
YesNo

If yes, details:

In the last ten years, has your client been treated for or been diagnosed as having: (please check all that apply)

Current Medications & Dosages

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?
YesNo

If yes, details:

Does the prospect own his/her own business?
YesNo

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?
YesNo

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 CorpS CorpProprietorshipPartnershipLLC

Buy/Sell Coverage

Would you like a proposal for Disability Buy Sell coverage?
YesNo

If yes, what is the total value of the business?

Buy Sell Trigger Point

Lump Sum:
YesNo

Monthly Funding:
YesNo

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:

Has the Bonus or Commission been consistent for the last 3 years?
YesNo

If no, Explain:

Total Retirement Plan Contributions

Type of Retirement Plan

Do you want to see a retirement plan protection product proposal?
YesNo

Other Disability Coverage Information:

Does the prospect have ANY other disability benefits (including Group STD or LTD)?
YesNo

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 Days30 Days60 Days90 Days

Benefit Period:
3 Months6 Months12 Months24 Months

Product Requested:
Accident OnlyAccident & Sickness

Long Term Disability

Elimination Period:
30 Days60 Days90 Days180 Days365 Days730 Days

Benefit Period:
6 Months12 Months2 Years5 Years10 YearsTo Age 65To Age 70Lifetime

Product Requested:
2 Years5 YearsTo Age 65To Age 67To Age 70Lifetime

Optional Provisions:

(Not all riders are available on all products)

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

Special Instructions:

Additional Information

Please provide any additional information...

Carrier Selection

Would you like us to recommend a carrier we feel provides the best value?
YesNo
(If you select NO, multiple quotes will be provided)

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FIND YOUR LOCAL PLUS GROUP® EXPERT

Don’t hesitate to contact your local Plus Group® office for more information on how an affiliation will benefit your practice and your clients.