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Individual / Business Overhead Expense

* Required Field

Broker Information
A value is required.
Address:
City:  State:  Zip:
* Phone: A value is required. Fax:
* Email: A value is required.
Affiliation or Referral:

Prospect Information
* First Name: A value is required.
 * Last Name: A value is required.
* Date of Birth: A value is required. * Resident State: A value is required.  Work State:  
* Gender: Please select a gender.
* Tobacco Use: Yes No Please make a selection
If yes:
Type:   Amount:
* Occupation: A value is required.
Duties:
Title:  Years in current position: 
Work from home:
  If Yes, percentage of time working in home:
 
Current Year Prior Year
* Annual Income: A value is required. 
Bonus:  
Commissions:  
Self Employed or
Business Owner:
Yes No
  If Yes,
  How long and percentage of ownership:
  How many employees:
  Type of business:
  If less than one year, prior occupation:

Individual Plan Design
Amount of Coverage:    or    Specific Amount:
Elimination Period:
Benefit Period:

Optional Riders
Residual/Partial:
This rider allows the insured to collect a proportionate benefit while returning to work part-time as long as there is a 20% or more loss of pre-disability earnings. Recommended for anyone purchasing a policy.
Own Occupation:
This rider allows the insured to return to work in another occupation and still be eligible for 100% of the monthly benefit. Recommended for physicians, dentists, attorneys and high income professionals only.
Cost of Living Adjustment:
This rider increases the insured’s monthly benefit each year while on claim. The increase is based on the change in the consumer price index. Recommended for those younger than age 50.
Retirement Protection:
This rider pays an additional monthly benefit into a trust during a total disability. The benefit amount is based on the employee and employer 401 (k) contribution. Recommended to those who have purchased the maximum amount of DI available.
Catastrophic Disability:
This is an additional benefit payable when there is a catastrophic disability. Catastrophic is usually defined as a loss of 2 of 6 Activities of Daily Living or a Cognitive Impairment.
If Yes, how much/month
Future Increase Option:
This rider allows the insured to purchase additional coverage without evidence of physical insurability. Recommended for young professionals whose incomes will increase significantly over time.
   

Premium Payor
Premium Payor:

Business Overhead Expense Plan Design
Monthly Expenses: :
Elimination Period:
Benefit Period:

Optional Riders
Residual/Partial:
This rider allows the insured to collect a proportionate benefit while returning to work part-time as long as there is a 20% or more loss of pre-disability earnings. Recommended for anyone purchasing a policy.
Future Increase Option:
This rider allows the insured to purchase additional coverage without evidence of physical insurability. Recommended for young professionals whose incomes will increase significantly over time.
In-force BOE Amount:
   

In-force Coverage
Group LTD: If yes, replacement %:
  If yes, monthly maximum:
Who pays for this coverage?       Are benefits taxable?
Definition of Earnings: Salary Bonus Commisions
   
Other Individual
Coverage:
Carrier Name:
Amount of Coverage:
Elimination Period:
Benefit Period:
Who pays for this coverage?
Is this coverage taxable?

Medical History
List any current medical conditions or medications taken:
Height and Weight:
Additional Information
Please provide any additional information about the insured that will help us provide you with the most accurate quote possible.  Example:  skydiving, flying as a pilot, parachuting, hang gliding, rock climbing, underwater diving or any other hazardous sport.

Carrier Choice
How would you like for
us to quote this case?
I would like my proposal
to be sent via:

 

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