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Request a Disability Quote
Producer
Agent Name
*
First
Last
Email
*
Phone
*
Client Information
Name
*
First
Last
Birthdate
*
Month
1
2
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4
5
6
7
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10
11
12
Day
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Year
2022
2021
2020
2019
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2017
2016
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2012
2011
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1971
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1952
1951
1950
1949
1948
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1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Male
Female
State
*
Select One
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
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Tobacco History
*
Never
Cigarettes
Cigar
Pipe
Smokeless
eCigs/Vape
Marijuana
Date of last use
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Height
*
4'8
4'9
4'10
4'11
5'0
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
5'10
5'11
6'0
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
6'10
6'11
7'0
7'1
7'2
7'3
7'4
7'5
7'6
Weight (lbs)
*
Any weight change in the last 12 months (specify amount and if lost or gained)?
Provide ALL medications, dosages, and frequencies.
Very Important! Provide any medical conditions. Tell your client you need full details of their medical history to avoid exclusions and wasted submits.
(Minor conditions like anxiety or ADHD could be excluded so it is important to get this up front).
Annual Income YTD
*
Annual Income prior year
*
Annual Income 2 years prior
*
Bonuses
Occupation / Duties
*
Business Owner
Yes
No
What type of business? And what are day to day duties?
Years of Ownership?
Total Average Monthly Expenses
Plan Design Information
Please complete for at least 1 plan type
Elimination Period (how many days can your client go without receiving a paycheck?
*
0 days
7 days
14 days
30 days
60 days
90 days
180 days
365 days
(How many days can your client live off of savings before they need this policy to start paying them? The shorter the elimination (waiting) period, the higher the premiums).
Benefit Period (how many days would your client need to receive income)?
*
30 days
60 days
90 days
180 days
1 year
2 years
5 years
10 years
to age 65/67 (retirement)
(The longer the Benefit period, the higher the premiums. How long would your client need to receive income if they were to go on claim)?
Monthly Benefit amount
*
Alternate Monthly Benefit amount, if requested
Anticipated annual premium budget
*
(Disability premiums are usually in the range of 1-2% of the clients salary. So for someone earning $50k a year, proposed premiums should be kept around $750 a year ($60 a month or $2 per day).
Optional Benefits / Riders (all increase the base premium).
Cost of Living Adjustment?
Yes
No
This rider increases your benefit to keep up with inflation.
Return of Premium?
Yes
No
You have the ability to surrender your policy and get a portion if not all of your premiums back.
Guaranteed Insurability Option Rider?
Yes
No
Allows the insured to purchase small amounts of additional insurance at certain policy years.
Additional comments, health concerns or benefits?