ICA Disability Income Questionnaire

Disability Income Questionnaire
Advisor Name
Advisor Email
example@example.com
Advisor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Hypothetical Quote Needed

MonthDayYear
Date
Client Name
Date of Birth

MonthDayYear
Sex:
Smoker:
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?
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 is supported by Lockton Affinity, LLC d/b/a Lockton Affinity Insurance Brokers LLC in California (#0795478). Lockton Affinity provides access to insurance and annuity solutions, as well as sales and case management support to ICA Insurance Services.

ICA Insurance Services and Lockton Affinity are not affiliated companies.
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