Agent Information
 

Agent Name: 

Phone: 

 (area) (xxx-xxxx)

Fax: 

 (area) (xxx-xxxx)

Please Send My Proposal By: 

  Fax
 Mail
 Mail, with application
 Email
**Address:
Email:
**Complete only if requesting illustration to be mailed.
 
 Client Information:
 
Name:
Birth Date: / /  (mm/dd/yyyy)
Sex: Male Female
State of Residence:
Tobacco Use: Yes No
If quit, last used: / /  (mm/dd/yyyy)
Height:
Weight:
Medical Problems/ 
Medications & Dosage:
(Family History of Cancer, Heart Attack, Stroke, Diabetes, Multiple Sclerosis or other diseases known to pass from previous generations)

 Work Information:
 
Occupation:
Job Duties:
Length of Employment:
Work out of Home? Yes No
If yes, details:
Does the prospect own his/her own business? Yes No
If yes, details including length of ownership, number of employees, etc.
Would you like a proposal for Business Overhead Expense coverage? Yes No
If yes, proposed Insured’s share of the monthly expenses?
 enter the dollar amount
What form of business? C Corp S Corp
Proprietorship Partnership LLC
 

 Taxability of Premium/Benefit Information:
Who will be paying the premium?
 Employer  Employee
 Taxable  Non-Taxable
What will the tax treatment of the proposed coverage be?

 Income Information:
(Income after business expenses but before taxes)
Annual Salary:
Bonus Or Commission:  Bonus:  Commission: 
Has the Bonus or Commission been consistent for the last 3 years? Yes No
If no, Explain:
Total Retirement Plan Contributions
Type of Retirement Plan
Do you want to see a retirement plan protection product proposal?
Yes No
 Illustration:
 

 Desired Quote Information:

 

Amount of coverage requested:

Special Instructions:
 
 Carrier Selection

 
Would you like the SDIC Marketing Team to suggest the one carrier we feel provides the best value for your client?

Yes No

(If you select NO, multiple quotes will be provided)

 

An illustration cannot be provided unless this form is completely filled out.
 
 
   
 
 
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