Individual Disability Worksheet
(Fields in red are required)

Producer Information

 

Name:

Email:

Phone:

Fax:

Preferred Mode of Contact:

Date:

 

  

Client Information

 

Gender:

Date of Birth:

State of Birth:

Is He/She Smoker?

Job Title:

Exact Job Duties :

Is He/She a Business Owner?

If yes, years of ownership:

Working out of Home?

Yes

# of Full Time Employees:

Current Coverage in Force?

Elimination Period:

 

  

Medical History

  

Plan Design Information

 

Plan Type:

If personal plan:

 

Elimination Period:

30 days
60 days
90 days
180 days
365 days

   

Benefit Period:

2 years
3 years
5 years
Age 65
Lifetime

   

If Business/Overhead Plan:

  

Elimination Period:

30 days
60 days
90 days

   

Benefit Period:

12 months
18 months
24 months

   

If Buy/Sell Plan:

 

Elimination Period:

12 months
18 months
24 months

   

Benefit Period:

Lump Sum
2 year
3 year
5 year

   

Monthly Benefit

 

Desired Amount:

Quote Maximum:

   

Riders

 

Future Increase Option:

COLA (Simple/Comp):

Residual:
   

Do you want a specific
company or product?

   

 

Please note: Disability Income Quotes are subject to many variables when designing the best plan for your client. You may receive a call to discuss this proposal request.