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June 8, 2023

Disability Insurance Quote Request Form

Stefan Bruckel

"*" indicates required fields

Financial Advisor Name*

First Last

Email*

Preferred Phone #*

By when do you need the illustration / proposal?

Email address(es) for others who should be cc'ed with our reply:

APPLICANT INFORMATIOIN

Name (Optional)

First Last

Gender

Male

Female

Birthdate

YYYY

Applicant's Resident State

List all tobacco products used in the past 12 months

Date of Last Tobacco Use

Never

Current user (used tobacco within past 12 months)

Past user, but not in past 12 months

US Citizen

Yes

US Permanent Resident (Green Card)

Yes

Pregnant

Yes

If pregnant, please provide due date

MEDICAL HISTORY

Height

Weight

Change in past 12 months

Please list all prescription medications you are taking

Have you ever been treated for neck or back disorders or pain? If yes, please describe and include date of last treatment.

Have you been diagnosed with prediabetes or diabetes? If yes, please provide date of diagnosis, Type 1 or Type 2, and typical A1c over past 12 months.

Are you being treated for high blood pressure?

Yes

Are you being treated for high cholesterol?

Yes

Have you ever been treated for mental or nervous disorders? If yes, please describe and include date of last treatment.

Please list all physicians, psychiatrists, psychologists, chiropractors, physical therapists, or other healthcare providers you have seen in the past 5 years. Please list the reason each has been seen.

Please tell us about any other medical history that might impact underwriting:

EXISTING DISABILITY INCOME INSURANCE COVERAGE

If you have Group Disability Insurance (employer) please list amount of coverage, waiting period, and benefit period:

If you already have personally owned Disability Income Insurance, please list the insurer, amount of coverage, waiting period, and benefit period:

If you have Association provided Disability Income Insurance, please list amount of coverage, waiting period, and benefit period:

Are you covered by a State or Federal Disability Income Insurance program (e.g. California's SDI)? Please provide amount of converge, waiting period, and benefit period:

OCCUPATION RELATED QUESTIONS

Please list all of your occupation(s) / jobs; please include duties and percent of time for each duty (example, bookkeeper, 50% accounting, 50% meeting with clients):

How long with current employer?

# Of employees at employer

# Of employees you supervise

Work from home?

Yes

Sometimes

Are you a city, state, or federal employee?

Yes

Self-employed?

Yes

If you answered yes to the work from home, government employee, or self-employed questions, please describe details. For example, work from home 30% / at office 70%

FINANCIAL QUESTIONS

Please list Gross Income (before taxes); if you are self-employed, provide income reported to IRS AFTER your expense deductions

$ Earned income this year

$ Earned income last year

$ Earned income 2 years ago

$ Unearned income this year

Interest, dividends, rent etc.

$ Unearned income last year

$ Unearned income 2 years ago

Please tell us about any bonuses or profit sharing you received in each of the past 3 years:

Does your net worth exceed $6,000,000?

Yes

Does your unearned income exceed 10% of earned income?

Yes

If you answered yes to the above two questions, please provide details and explain:

BUSINESS OWNER QUESTIONS

Describe type of business

Years of ownership

Percentage of ownership

$ Gross annual business income

$ Annual business expenses

$ Net income

If you are looking for Business Overhead Expense coverage, what are your monthly expenses?

If you are looking for Buy-Out coverage, how much coverage do you need?

If you are looking for Buy-Out coverage, are the co-owners similarly insured for their percentage of ownership? If not, please explain why not (e.g. cannot qualify for coverage):

POLICY DESIGN OPTIONS - PERSONAL COVERAGE

Elimination Period(s)

Benefit Period(s)

Monthly Benefit Amount

Quote Maximum Available

Yes

Premium Mode

Annual

Semi-Annual

Quarterly

Monthly

POLICY DESIGN OPTIONS - BUSINESS COVERAGE

Elimination Period(s) for BOE

Benefit Period(s) for BOE

Monthly Benefit Amount for BOE

Quote Maximum Available

Yes

Premium Mode

Annual

Semi-Annual

Quarterly

Monthly

Buy-Out Elimination Period(s)

Buy-Out Coverage Amount

Quote Maximum Available

Yes

Premium Mode

Annual

Semi-Annual

Quarterly

Monthly

RIDERS AND OTHER BENEFITS

Own Occupation Rider

Yes

Other Riders

If a prior application was rated or declined, please tell us with which carrier, when, and why.

Please provide any other information that would help us provide you with the best coverage options for your client. Thank you!

Upload Exams, Lab Results, HIPAAs etc.

Max. file size: 50 MB.

June 7, 2023

Annuity Quote Request Form

Stefan Bruckel

"*" indicates required fields

Financial Advisor Name*

First Last

Email*

Phone*

By when do you need the illustration / proposal?

Email address(es) for others who should be cc'ed with our reply:

Allowed to Sell Indexed Annuities?

Yes

Broker/Dealer:

ANNUITANT INFORMATION

Annuitant Name

First Last

Date of Birth

Gender

Male

Female

State of Residence

ANNUITY DESIGN

Premium Amount

Tax Qualified

Yes

Annuity Type

Single Premium Immediate Annuity (SPIA)

Deferred Income Annuity (DIA)

Design

Fixed

Indexed

Fixed Annuity Term (Years)

SPIA Payment Option

Index Income Rider? When to start?

Additional comments or competitive information:

June 7, 2023

Long-Term Care Insurance Quote Request Form

Stefan Bruckel

"*" indicates required fields

Financial Advisor Name*

First Last

Email*

Preferred Phone #*

By when do you need the illustration / proposal?

Email address(es) for others who should be cc'ed with our reply:

APPLICANT INFORMATION

Applicant Name

First Last

Date of Birth

MM slash DD slash YYYY

Risk Class

Preferred

Standard

Rated

Marital Status

Married

Single

State of Residence

Height

Weight

Has applicant ever used tobacco?

Yes

Specify type & date of last use

Prior Applications - please list prior applications with carrier, dates, and underwriting outcome:

Medications

Medical History

SPOUSE COVERAGE

Spouse Name

First Last

Spouse Date of Birth

MM slash DD slash YYYY

Spouse Risk Class

Preferred

Standard

Rated

State of Residence

Height

Weight

Has applicant ever used tobacco?

Yes

Specify type & date of last use

Prior Applications - please list prior applications with carrier, dates, and underwriting outcome:

Spouse Medications

Spouse Medical History

LONG TERM CARE POLICY DESIGN

Benefit Amount

Spouse Coverage Options

Two Individual Policies

Survivorship / Joint Lives

Maximum Annual Premium

Benefit Payment Options at Time of Claim

Tax-free cash benefits that can be used for any purpose, including paying family, friends, or neighbors, without restrictions.

Tax-free benefits that limit benefits to professional care, or care in an institutional setting.

Show me both cash indemnity and professional care only policy options.

Elimination Period(s)

Benefit Period(s)

Inflation Rider Type and Percentage

Riders: Shared Care, Return of Premium, Restoration of Benefits, Waiver of Premium, Other - please specify):

Design Instructions (e.g. Survivorship / Joint Lives Option)

Do you have other information we should know as we develop proposals?

EXPERT HELP IS AVAILABLE

Do you focus on investments or other lines of insurance? Would you prefer not to have to invest time studying LTC policy variants? Help is available! We can introduce you to an LTC Insurance Expert. They are familiar with policy options and how clients can leverage the tax code to their maximum advantage. Once the Expert understands what your client is trying to accomplish, they will guide them toward a policy design and benefit payment option that’s right for them - and within their budget. Expert services are provided on a joint work basis, negotiated between you and the Expert.

Would you like to talk to a LTC Expert to strategize regarding a joint work arrangement?

Yes

Tell me more about how that might work

Upload Exams, Lab Results, HIPAAs etc.

Max. file size: 50 MB.

June 7, 2023

Life Insurance Quote Request Form

Stefan Bruckel

Prefer to run your own quotes? You can access our quote engine here Run a Quote.

CA Corp. Insurance License: 0E02059

Let's Connect

Phone: (562) 431-4000

Email: requests@cpsadvantage.com

Mail & Overnight Address

CPS Advantage
3020 Old Ranch Parkway #300
Seal Beach, CA 90740