Disability quote request
This quote request is for a(n)...
Individual
Business
Broker information
Agent's name
Agent's MVP Contact
Please select...
Dawn Nelson
Matt LaLonde
Joe Carey
Jodi Waldera
Fred Thorbahn
Scott Thorp
Michael Zingale
Mary Lou Paul
Jim Chrisler
Other / None of the above
Agent's email address
Agent's cell phone
Business policy details
Business case; check products to quote
Business Overhead Expense (BOE)
Key Person Replacement DI Policy
Disability Buy-Out Policy
Business Loan Protection (Rider or stand-alone)
Business Overhead Expense (BOE) Information
Total monthly expenses (salaries, rent/mortgage, utilities, loans, office supplies, taxes, etc.)
Elimination period(s)
30 days
60 days
90 days
Benefit period(s)
12 months
18 months
24 months
Key Person Replacement DI Policy Information
Annual income of the Key Person
Monthly Benefit, Lump Sum or combination
Monthly Benefit
Lump Sum
Combination
Monthly Benefit Elimination period(s)
90 days
180 days
Lump Sum Benefit Elimination period(s)
180 days
365 days
730 days
Disability Buy-Out Policy Information
Client's Business Value / Value of business ownership
Elimination period(s)
365 days
540 days
730 days
Monthly benefit period(s)
24 months
36 months
60 months
Monthly Benefit, Lump Sum or combination
Monthly Benefit
Lump Sum
Combination
Business Loan Protection Information
Is this a rider on a BOE policy or a stand-alone policy?
Rider on BOE policy
Stand-alone policy
Total amount of the loan
$
Loan effective date
Loan effective date
Elimination period(s)
30 days
60 days
90 days
180 days
365 days
Insured's information
Insured's name
Insured's gender
Insured's date of birth
Resident state
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Current disability income (including coverage through an employer)
Benefit / Type
Government employee?
Yes
No
Occupation / Job Duties
Annual salary (if commissions use 3 year average)
Bonus
Ever filed for bankruptcy?
Yes
No
Bankruptcy information
File date
Chapter
Completed date
W2 employee or self-employed?
W2 employee
Self-employed
Monthly income
$
Self-employment information
Self-employed for how long?
Ownership %
%
Number employees
Type (LLC, C-corp, etc)
Net income this year (after expenses)
Net income last year (after expenses)
Insured's personal health information
Height (
feet
)
ft
Height (
inches
)
in
Weight
lbs
Has proposed insured had any weight change in excess of 10 lbs
.
in the past year?
Yes, lost weight
Yes, gained weight
No
Change amount
lbs
Reason(s) for weight change
Tobacco / Nicotine use
Yes
No
Tobacco / nicotine use information
Type(s) used
Cigarettes
Cigars
Pipe
Chewing tobacco
Nicotine vape
Non-vape nicotine product (gum, pouch, patch)
Frequency of use
Date of last use
Back / neck problems?
Yes
No
Back / neck problem information
Chiropractic
Date last seen
Details
Is proposed insured diabetic?
Yes
No
Diabetes information
Type
Age onset
Details
Has proposed insured had a sleep study / disorder?
Yes
No
Sleep study / disorder information
Disorder (e.g. apnea, respiratory)
C-pap use?
Details
Hypertension?
Yes
No
Hypertension information
Date diagnosed
Last reading
Reading date
Cancer?
Yes
No
Cancer information
Type
Location
Last treatment
Drug / alcohol abuse?
Yes
No
Drug / alcohol abuse information
Type
Amount
Treatment date(s)
Has proposed insured ever used any of the following (check all that apply)
Cane / Walker
Crutches
Wheelchair
When?
Any medications?
Yes
No
Medication information
Rx name
Dosage
Date prescribed
If you need to add another, click or tap "Add another medication" below
Does proposed insured have existing disability coverage?
Yes
No
Existing coverage information
Premium payor (employer/employee)
Monthly benefit amount or percentage of income
Case design
Is proposed insured the premium payor?
Yes
No
Premium payor
Specify benefit amount or write MAX
$
Elimination period requested
Benefit period requested
Options requested
Partial/residual
Cost of living
Future purchase rider
Retirement plan deferral
Automatic increase
Future purchase rider $
$
Retirement plan deferral $
$
Automatic increase
Other requests (optional)
Additional information: Please list any additional comments or information that will assist us in properly preparing your quote.
Contact Information