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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