Online Request for DI Quote

Request a Disability Quote

Producer
Agent Name*
First Last
Email*
Phone*
Client Information
Name*
First Last
Birthdate*
Gender*
- Male
- Female
State*
Tobacco History*
Date of last use
Height*
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?

Contact Us

Phone: 610-785-1501

Fax: 267-295-7947

SALES@VICTORYBROKERAGE.COM

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Online Request for DI Quote

Request a Disability Quote

Producer

Client Information

Plan Design Information

Optional Benefits / Riders (all increase the base premium).