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Disability Insurance Quote Request Form
"
*
" 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
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YYYY
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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
No
US Permanent Resident (Green Card)
Yes
No
Pregnant
No
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?
No
Yes
Are you being treated for high cholesterol?
No
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?
No
Yes
Sometimes
Are you a city, state, or federal employee?
No
Yes
Self-employed?
No
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?
No
Yes
Does your unearned income exceed 10% of earned income?
No
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
No
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
No
Premium Mode
Annual
Semi-Annual
Quarterly
Monthly
Buy-Out Elimination Period(s)
Buy-Out Coverage Amount
Quote Maximum Available
Yes
No
Premium Mode
Annual
Semi-Annual
Quarterly
Monthly
RIDERS AND OTHER BENEFITS
Own Occupation Rider
Yes
No
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!
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