ICA Disability Income Questionnaire

Disability Income Questionnaire
Advisor Name*
Advisor Email*
example@example.com
Advisor Phone Number
Please enter a valid phone number.
Date Hypothetical Quote Needed*

MonthDayYear
Date
Client Name*
Date of Birth*

MonthDayYear
Sex:*

MaleFemale
Smoker:*

YesNo
State of Residence*
Occupation/Exact Job Duties*
Ownership/Type of Business Sole proprietor, partnership, S-corp., C-corp*
Health Concerns: HT/WT, Back & Neck, Heart Disease, Stroke, Cancer, Mental & Nervous, etc.*
Insurable Income
Salary (W-2)*
Average bonus/commissions*
(Business Owners) Share of company profit (K-1)*
Company provided pension 401k match, profit sharing, etc*
Total Income *
Unearned Income*
Inforce Disability Coverage
Do you have any inforce disability coverage?*

YesNo
If "yes" to having inforce disability coverage, please complete the following questions (1-6).
1 - Individual, group LTD, or BOE
2- Elimination period/benefit period
3- Benefit amount (% or specified)
4- Plan maximum
5- Premium paid by employer or insured
6- Riders
Please provide any additional details regarding this case.
ICA Insurance Services are administered by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers LLC in California #0795478. Coverage is subject to actual policy terms and conditions. Policy benefits are the sole responsibility of the issuing insurance company.
Should be Empty: