DISABILITY PROPOSAL REQUEST


Agent Information

Agent:
Phone:
Office:
E-mail:
Contact:
    


Client Information

Prospect Name:
State of Residence:
Age:
 Gender: Male Female
Occupation:
 Tobacco Use? Yes No
Specific Duties:
Who is paying the Premium?
Income:
Employee
      Employer
Group LTD $
Individual DI $
Is there other coverage in force?
Yes No    
Medical Conditions:


Benefits to Quote

Disability Insurance
Monthly Benefit:
 $
Elimination Period:
 30 days 60 days 90 days 180 days 365
days 730 days
Benefit Period:
 2 years 5 years Age 65 Age 67 Lifetime
Optional Benefits:
 Own occ Residual COLA Future Purch. Opt. SDIR
Show All Purch. Opt.

Business Overhead Expense
Monthly Benefit:
 $
Elimination Period:
 30 days 60 days 90 days
Benefit Period:
 12 months 18 months 24 months
Optional Benefits:
 Residual Residual Salaray of Replacement
Show All Purch Opt

Disability Buy-Out

Monthly Benefit:
 $ or Lump Sum Benefit:
Elimination Period:
 12 months 18 months 24 months
Benefit Period:
 Lump Sum 18 months 24 months 36 months
60 months
Total Coverage Desired:
$

Comments: