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 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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