• Client Information

• Client Name:
• Home State:
• Gender:
  • Male
  • Female
• Age/DOB:
• Smoker:
  • Yes
  • No
• Height:
• Weight:
• Medications/Health conditions including any Psychological and Chiropractic care)?:
• Annual Income (Current Year):
• Last Year:
• Other DI/LTD inforce?:
  • Yes
  • No
• Current total individual monthly benefit:
• Group percentage:
• Group maximum:
• Other:

• Occupation & Duties -

• Occupation:
• Title:
• Years in Present Occupation:
• Degree:
• In what field:
• Exact Job Duties (Vital for accurate quote):
• % Administration:
  Please enter a value between 0 and 100.
• % Travel:
• % Sales:
• % Manual Labor:
• % Managerial:
• % Other:
• Number of employees supervised:

• Business Ownership Status -

  (necessary information for Occ-Class upgrade)
• Business Owner:
  • Yes
  • No
• If yes, how many years?:
• Business Entity:
  • Sole Prop
  • Partnership
  • LLC
  • LLP
  • S-Corp
  • C-Corp
• Number of Employees:
• Office in Residence:
  • Yes
  • No
• If yes, percentage of time away from residence:

• Product Options -

• Most Important:
  • Cost
  • Superior Benefit
  • Monthly Benefit Maximum
• Requested Premium Amount:
• Premium Level:
  • Level Pay
  • Step Rate
  • Employee Paid
  • Employer Paid
• Payment Mode:
  • Annual
  • Semi-Annual
  • Quarterly
  • Monthly
• Type of DI Product:
  • Individual
  • DI Business Overhead
  • Buy/Sell
  • Key Person
• Elimination Period:
  • 30
  • 60
  • 90
  • 180
  • 365
  • 730
• Benefit Period:
  • 6 Months
  • 1-5 Years
  • To Age 65
  • To Age 70
• Choose # of years:
  • 1 year
  • 2 years
  • 3 years
  • 4 years
  • 5 years