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Disability Insurance Proposal

Submitted by administrator on Tue, 07/21/2009 - 12:18
 Submission Routing
 
Your Location:  
 
 Producer Information
  
Name:
Phone:
(area) (xxx-xxxx)
Fax:
(area) (xxx-xxxx)
Email:

All proposals and product information will be sent to you by email unless we are instructed otherwise.

 
 Client Information:
 
Name:
Birth Date: / /
(mm/dd/yyyy)
Sex: Male Female
State of Residence:
Marital Status:
Tobacco or Nicotine Use: Yes No
Type of Tobacco or Nicotine:
If quit, last used: / /
(mm/dd/yyyy)
Details:
 
Medical Information
 
Current Height:
Current Weight:
Has there been a weight change of more than 10 lbs in the last year? Yes No
If yes, details:

 

In the last ten years, has your client been treated for or been diagnosed as having: (please check all that apply)

Current Medications & Dosages:
High blood pressure, chest pain, heart murmur or disorder of the heart or circulatory system
Diabetes, cancer, tumor, disorder of the thyroid, pancreas or lymph nodes or disorder of the glands, bone, blood or skin
Complication of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system
Hernia, Hepatitis or disorder of the liver, gall bladder, appendix, stomach, intestines or rectum
Arthritis, rheumatism, gout or disorder of the joints, limbs or muscles
Disorder or condition of the back, neck or spine including "wellness" chiropractic visits
Tuberculosis, Allergy, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system
Epilepsy, stroke, dizziness, headache, paralysis or disorder of the brain or spinal cord
Disorder of the eyes, ears, nose or throat
Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorder or counseling for personal or work issues
Chronic Fatigue Syndrome, Epstein Barr virus or Lyme disease
Treatment for drug or alcohol abuse or use of any controlled substance
Has your client been rated, declined or offered modified coverage from any life or health insurance carrier
In the last 5 years has your client visited a physician, clinic or medical practitioner for treatment of any disease or disorder or been advised to begin any treatment program?
Details:
 Please enter details for any box checked
Employment Information:
Occupation:
Specific Job Duties:
Length of Employment:
Work out of Home? Yes No
If yes, details:
Does the prospect own his/her own business? Yes No
If yes, details including the percentage of ownership, how long the prospect has owned the busness, number of employees, etc.? This is IMPORTANT for obtaining the best occupation class possible
BOE Coverage
Would you like a proposal for Business Overhead Expense coverage? Yes No
If yes, what is the total monthly overhead expense for the business?
What is the proposed insured’s percentage of ownership
What form of business? C Corp S Corp Proprietorship Partnership LLC
Buy/Sell Coverage
Would you like a proposal for Disability Buy Sell coverage? Yes No
If yes, what is the total value of the business?
Buy Sell Trigger Point:
Lump Sum: Yes No
Monthly Funding: Yes No
 
Taxability of Premium/Benefit Information:

Who will be paying the premium? Employer Employee
What is the preferred tax treatment of the benefits when received? Taxable Non-Taxable

Income Information:
(Income after business expenses but before taxes)
Salary: Current YTD:

Last Tax Year:

Bonus: Current YTD:

Last Tax Year:

Commission: Current YTD:

Last Tax Year:

Has the Bonus or Commission been consistent for the last 3 years? Yes No
If no, Explain:
Total Retirement Plan Contributions
Type of Retirement Plan
Do you want to see a retirement plan protection product proposal? Yes No
Other Disability Coverage Information:

Does the prospect have ANY other disability benefits (including Group STD or LTD)? Yes No
If yes, please provide details, including the taxability of the benefits when received, benefit maximums, elimination period, etc.
 
 Illustration:
 
Desired Illustration Information
(Not all carriers provide all benefits or options or make them available to all risk classes -
we will attempt to match your quote as closely as possible to your request)
Short Term Disability  
Elimination Period: 14 Days 30 Days 60 Days 90 Days
Benefit Period: 3 Months 6 Months 12 Months 24 Months
Product Requested: Accident Only Accident & Sickness
Long Term Disability  
Elimination Period: 30 Days 60 Days 90 Days 180 Days 365 Days 730 Days
Benefit Period: 6 Months 12 Months 2 Years 5 Years 10 Years To Age 65 To Age 70 Lifetime
Own Occupation Period: 2 Years 5 Years To Age 65 To Age 67 To Age 70 Lifetime
Optional Provisions:
(Not all riders are available on all products)
Specialty Own Occupation
Transitional Your Occupation
Residual (24 Months)
Residual (To Age 65, To Age 67 or To Age 70)
COLA (Minimum)
COLA (Maximum)
Catastrophic/ADL Rider
Future Purchase Option(s)
Group Replacement/Supplemental Rider?
Social Insurance Offset Rider
Partial Disability
Return of Premium
Treatment of Injuries or Hospital Benefits
Long Term Care Guaranteed Purchase Rider
Retirement Protection Benefits
 
Special Instructions:
 
Additional Information
 
Please provide any additional information...
 
Carrier Selection
 
Would you like us to recommend a carrier we feel provides the best value? Yes No

(If you select NO, multiple quotes will be provided)

 
An Illustration cannot be provided unless this form is completely filled out.