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Disability Insurance Proposal

Please submit a request for proposal using the form below. We will begin to process your request immediately.

Please provide us with as much information as possible, so we can insure that your quote will be processed accurately and in a timely manner.

 Agent Information
Agent Name:
(area) (xxx-xxxx)
(area) (xxx-xxxx)

Note: All proposals and product information will be sent
to you by email unless we are instructed otherwise.

 Client Information:
Birth Date: / /
Sex: Male Female
State of Residence:
Marital Status:
Tobacco Use: Yes No
Medical Information
Medications & Dosages:
In the last five years, has your client been treated for or received medical advice?
List Details:
Employment Information:
Job Duties:
Length of Employment:
Work in your Home? Yes No
If Yes, percentage of time spent in home office:
Does the prospect own his/her own business? Yes No
If yes, details including the percentage of ownership, how long the prospect has owned the busness, 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? Yes No
If yes, proposed Insured's share of the monthly expenses?
Buy/Sell Coverage
Would you like a proposal for Disability Buy Sell coverage? Yes No
If yes, provide the value of the business:
Buy Sell Trigger Point:
Lump Sum: Yes No
Monthly Funding: Yes No
Income Information:
(Income after business expenses but before taxes)
Annual Salary: Most Recent/Current
Last Complete Tax Year
Bonus: Most Recent/Current
Last Complete Tax Year
Commission: Most Recent/Current
Last Complete Tax Year
Has the Bonus or Commission been consistent for the last 3 years? Yes No
If no, Explain:
Other Coverage Information

Does the prospect have ANY other disability benefits (including Group Std or Ltd)? Yes No
If yes, Details including taxability of the benefit,benefits maximums, elmination period, etc.
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)
Long Term Disability Information  
Elimination Period: 30 Days 60 Days 90 Days 180 Days 365 Days 730 Days
Benefit Period(s): 6 Months 12 Months 2 Years 5 Years 10 Years To Age 65 Age 67
Own Occupation Period: 2 Years 5 Years Age 65 Age 67 Age 70 Lifetime
Optional Provisions:
(Not all riders are available on all products)
Special Instructions:
Additional Information
Please provide all additional information which may assist in generating an accurate illustration. Include information such as special travel, avocations or hobbies, special work circumstances or history, etc.
Carrier Selection
Would you like us to suggest the one carrier we feel provides the best value for your client? Yes No
(If you select NO, multiple quotes will be provided)
An Illustration cannot be provided unless this form is completely filled out.