DI Quote IIB

Disability Insurance Quote Request
Agent/Advisor Information
Agent/Advisor Name*

First NameLast Name
E-Mail*
Phone Number*
Agent/Advisor State*
Client Information
Client Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Clients State*
Height:
Weight:
Tobacco?*
Years used?*
Client Occupation*
Specific Occupational Duties*
Hours Worked Per Week
Years Employed In Current Industry
Percentage Of Ownership
Annual Gross Income *
Annual Net Income*
Employment*

Salaried (Salary + Bonus)Self-employed – Sched. C (Income-Expenses)Partner or S-Corp (Income from K-1)
Do You Have Other Coverage In Force ?*

YesNo
How is it Paid?

Employer Paid PremiumEmployee Paid Premium
Group LTD Amount
Benefit / Elimination Period
Individual DI Amount
Benefit / Elimination Period
Quote Information
Benefit*

Short TermLong Term
Benefit Amount (Monthly)*

Max AvailableSpecified Amount
Amount %
Long Term Elimination Period

30 Days60 Days90 Days180 Days365 Days
Long Term Benefit Period

2 Year5 Year10 YearTo Age 65To Age 67
Short Term Elimination Period

0 Days7 Days14 Days
Short Term Benefit Period

3 Month6 Month12 Month24 Month
Rider Selection

Own OccupationCOLA / InflationFuture Purchase OptionSocial Security / DI Insurance (SDIR)Automatic Benefit IncreaseCatastrophic DisabilityCritical IllnessGuaranteed InsurabilityNon-CancelableResidual / Partial DisabilityRetroactive Injury BenefitReturn Of Premium
Business Overhead Expense
Business Overhead Expense (BOE) Quote Request

YesNo
Monthly Benefit Amount
Elimination Period

30 Days60 Days90 Days
Benefit Period

12 Month18 Month24 Month
Riders

Future Purchase OptionSalary Of ReplacementResidual
Disability Buy out
Disability Buy Out Quote Request

YesNo
Monthly Benefit
Lump Sum Benefit
Elimination Period

12 Month18 Month24 Month
Benefit Period

18 Month24 Month36 Month60 MonthLump Sum
Medical History
Does The Client Have Any History of:*

Neck Or Back DisordersMental Or Nervous ConditionsDiabetes, High Cholesterol, HypertensionOtherN/A
Other History:
In The Last Five Years Has The Client Seen:*

PhysiciansCounselors / PsychiatristsChiropractorN/A
Is The Client Pregnant*

YesNo
If yes was answered to any previous questions please explain here: (Full Details, Treatments, Procedures, Durations, Conditions) If None put N/A *
Additional Notes or Preferences on Quotes:
For Questions Please call 317-663-0061
Should be Empty:

Disability Insurance Quote Request

Agent/Advisor Information

Client Information

Quote Information

Business Overhead Expense

Disability Buy out

Medical History

For Questions Please call 317-663-0061