Disability Quote Request

Broker Information

Broker Name *

Phone # *

Fax

E-mail *

Date

Client Information

Client's Name *

Date of Birth *

Sex *

Male Female

State *

--Select State-- AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Tobacco ? *

Yes No

Business Name

Job Title and Duties *

Annual Income + any bonuses *

Business Owner? *

Yes No

If Yes, How many years of ownership ? 

How many fulltime employees ? 

Percentage of Ownership :

%

Existing Coverage

Yes No

Individual Group

If Yes, What Carrier?

Elimination Period *

Benefit Period *

Plan Design Information

Plan Type *

Personal Business Overhead Buy/Sell Keyman

Carrier

Mutual of Omaha Principal Ameritas The Guardian Assurity The Standard

Elimination Period

Personal

-Select- 90 180 730 365

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 %

Catastrophic Benefit

Future Purchase Option

Yes No

Other

Additional Information

Please indicate any special health/underwriting considerations

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