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Disability Quote Form

CLIENT INFORMATION    
Your Name* Company:  Owner-Self employed C-corp
Your Date of Birth*: Industry:
Sex*:  Male Female Number of Employees:
Your State*: Years in Business:
Your Zip Code*: Number of Years Ownership:
Your Phone*: Percentage of Ownership:
Your Email*:    
Tobacco User?  Yes No Government Employee:  Yes No
    Branch:  Federal State County City
Net Annual Income*: Number of Years:
Occupation*: Group LTD In Force?  Yes No
Number of Years* Monthly Amount: $
Work at home:  Yes No Percentage:  60% 67%
Percentage of Time: Employer Paid:  Yes No
% of Time Traveling*: Individual Coverage In Force?  Yes No
    Monthly Amount: $
    To Remain In Force?  Yes No
       
Exact Occupation Duties:
Medical Issues or Other Comments :
       
INDIVIDUAL DISABILITY POLICY    
Premium Paid By?  Employer Employee Monthly Benefits: $
Elimination Period:  60 90 180 365 Benefit Period:  2 yrs 5 yrs to age 65 66/67
Benefit Riders:  SSIB Residual benefits COLA Non-cancelable Return of premium CAT Own Occ. Future purchase option Lifetime No riders
       
OVERHEAD EXPENSE POLICY    
Monthly Benefits: $ Benefit Period:  12 mos 18 mos 24 mos
Elimination Period:  30 60 90 Benefit Riders:  Residual benefits Future purchase option
       
     
       
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