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Disability Quote Form











CLIENT INFORMATION   
Your Name*: Company: Owner-Self employed C-corp
Your Date of Birth*:Industry:
Sex*: Male FemaleNumber of Employees:
Your State*:Years in Business:
Your Zip Code*:Number of Years Ownership:
Your Phone*:Percentage of Ownership:
Your Email*:  
Tobacco User? Yes NoGovernment Employee: Yes No
  Branch: Federal State County City
Net Annual Income*:Number of Years:
Occupation*:Group LTD In Force? Yes No
Number of Years*Monthly Amount: $
Work at home: Yes NoPercentage: 60% 67%
Percentage of Time:Employer Paid: Yes No
% of Time Traveling*:Individual Coverage In Force?  Yes No
  Monthly Amount: $
  To Remain In Force? Yes No
    
Exact Occupation Duties:
Medical Issues or Other Comments :
    
INDIVIDUAL DISABILITY POLICY   
Premium Paid By? Employer EmployeeMonthly Benefits: $
Elimination Period: 60 90 180 365Benefit Period: 2 yrs 5 yrs to age 65 66/67
Benefit Riders: SSIB Residual benefits COLA Non-cancelable Return of premium CAT Own Occ. Future purchase option Lifetime No riders
    
OVERHEAD EXPENSE POLICY  
Monthly Benefits: $Benefit Period: 12 mos 18 mos 24 mos
Elimination Period: 30 60 90Benefit Riders: Residual benefits Future purchase option
    
   
    
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