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Disability Quote
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Disability Quote
Disability Insurance Quote Request
Request a Disability Insurance Quote
Step 1 of 3 - Agent Information
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Agent Information
Name
*
Phone
Fax
Email
*
Client Information
Name
*
Date of Birth
*
Month
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Male
Female
State of Residence
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Georgia
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Marital Status
*
Single
Married
Domestic Partner
Widowed
Divorced
Tobacco Use
*
Yes
No
Medical Information
Height
Weight
Medications and Dosages
In the last five years, has your client been treated for or received medical advice?
List details above
Employment Information
Occupation
Job Duties
Length of Employement
Works from home?
No
Yes
Work at home details
Owns their own business?
No
Yes
How many years have they owned their business?
How many employees?
Income Information
Income after business expenses but before taxes
Annual Salary
Bonus
Commission
Has bonus/commission been consistent for the past three years?
Yes
No
Please explain inconsistent commission
enter details here
Other Coverage Information
Does the client have any other disability benefits (including Std or Ltd)?
If yes, please list details including taxability of the benefit, benefit maximums, elmination period, etc.
Illustration Information
Elimination Period
None
30 Days
60 Days
90 Days
180 Days
365 Days
730 Days
Benefit Period
None
6 Months
12 Months
2 Years
5 Years
10 Years
To Age 65
Age 67
Own Occupation Period
None
2 Years
5 Years
Age 65
Age 67
Age 70
Lifetime
Would you like a proposal for Business Overhead Expense (BOE) coverage?
No
Yes
BOE Details
Please enter any details such as proposed insured's share of the monthly expenses.
Would you like a proposal for Buy Sell coverage?
No
Yes
Buy/Sell Coverage Details
Please list Buy/Sell coverage details including business value, trigger point, lump sum and monthly funding.
Optional Provisions
Own Occupation
Modified Own Occupation
Cola(Minimum) after 12 mos of paid disability
Cola(Maximum) after 12 month of paid disability
Residual/Partial
Future Increase Option
Group Replacement/Supplement Rider
Return of Premium
Catastrophic/ADL Rider
Social Insurance Offset Rider
(not all riders are available on all products)
Special Instructions
Would you like us to suggest the one carrier we feel provides the best value for your client?
Yes
No
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