Disability Income Insurance Proposal Request
What type of disability coverage are you interested in? (Select all that apply)
*
Short-Term Disability (STDI)
Long-Term Disability (LTDI)
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Client Information
Your Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Gender
*
Please Select
Male
Female
Primary Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is this a cell phone or landline
*
Please Select
Cell Phone
Landline
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email Address
*
example@example.com
It's okay to communicate with me via:
Email
Text
Are You Self Employed?
*
NO
YES
Self Employed Since
*
/
Month
/
Day
Year
Date
Primary Occupation
*
Occupation Duties
*
Annual Income from Primary Occupation
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Short-Term Disability Income (STDI)
Benefit Amount (STDI)
*
Max
Monthly $
Benefit Period (STDI)
*
3 Mo
6 Mo
12 Mo
24 Mo
Elimination Period: How long do I have to be off work before my policy pays me benefits (Days)Elimination Period
*
0/7
7
0/14
14
30
60
90
Unsure
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Long-Term Disability Income (LTDI)
Benefit Amount
*
Max
Monthly $
Benefit Period
*
By Year
By Age
Benefit Period, Until Age
*
65
67
70
Benefit Period
*
2 Years
5 Years
Riders/Options
*
Social Insurance Supplement
Automatic Increase
Future Increase
Residual
COLA
Catastrophic
Return of Premium 50%
Return of Premium 80%
True Own Occupation
Unsure
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Health History
Do you use any tobacco or nicotine products?
*
YES
NO
FORMER USER
Quit Date
*
/
Month
/
Day
Year
Date
Which of the following products do/did you use? (Check all that apply)
*
Cigarettes
Cigars
Chewing tobacco / smokeless tobacco
E-cigarettes / Vaping devices
Nicotine patches or gum
Other
Do you have any chronic conditions? (Heart Disease, Diabetes, Asthma, etc...)
YES
NO
If you'd like to describe any details about your chronic conditions, it may be helpful in recommending plans
Do you take any prescribed medications?
*
YES
NO
Prescribed Medications
*
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Additional Comments
Is there anything else you'd like us to know?
*
Please Select
No
Yes
If there's anything else you'd like us to know, please leave it below
Confidentiality Notice
All information contained in this questionnaire is strictly confidential and used solely for seeking benefits to match the best plan for your needs. *Consulting Agreement fee may be required. You can reach us directly anytime at 706-257-5073 or info@michellecrawfordbenefits.com
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