Disability Quote Request
Fill in the form below to receive a Disability Illustration:
All Fields Are Required
Agent Information
Agent's Name:
Phone #: :
Fax #:
Date:
Client Information
Client's Name:
Date of Birth:
Sex:
Male
Female
State:
Tobacco:
Yes
No
Job Title and Duties:
Annual Income + any bonuses:
Business Owner?:
Yes
No
If Yes, Years of Ownership:
# of Fulltime Employees:
Existing Coverage:
Individual:
Group:
Elimination Period:
Benefit Period:
Plan Design Information
Plan Type: Personal
Business Overhead
Buy/Sell
Elimination Period
Personal:
-Select-
90
180
365
730
Business Overhead:
-Select-
30
60
90
Buy/Sell
-Select-
365
540
730
Benefit Period
Personal:
-Select-
2
3
5
Age 65
Age 67
Business Overhead:
-Select-
365
15 Mos
24 Mos
Buy/Sell
-Select-
Lump Sum
2 yr
3 yr
5 yr
Monthly Benefit
Desired Amount:
Quote Maximum:
Optional Benefits
Cola %:
Other:
Additional Information:
Please indicate any special health/underwriting considerations.
A disability illustration cannot be provided unless
this form is completely filled out.