Agent Information
 

Agent Name: 

Phone: 

 (area) (xxx-xxxx)

Fax: 

 (area) (xxx-xxxx)
Email:

All proposals and product information will be
sent to you by email unless we are instructed otherwise.

 
 Client Information:
 
Name:
Birth Date: / /  (mm/dd/yyyy)
Sex: Male Female
State of Residence:
Marital Status:
Tobacco Use: Yes No
Type of Tobacco
If quit, last used: / /   (mm/dd/yyyy)
Details:
 

 Medical Information:
Height:
Weight:
Medications & Dosages:
Has there been a weight change of more than 10 lbs in the last year?
 Yes No
If yes, details:
In the last five years, has your client been treated for or received medical advice for the following:
(please check all that apply)
High blood pressure, chest pain, heart murmur or disorder of the heart or circulatory system
Diabetes, cancer, tumor, disorder of the thyroid, pancreas or lymph nodes or disorder of the glands, bone, blood or skin
Complication of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system
Hernia, Hepatitis or disorder of the liver, gall bladder, appendix, stomach, intestines or rectum
Arthritis, rheumatism, gout or disorder of the joints, limbs or muscles
Disorder or condition of the back, neck or spine including "wellness" chiropractic visits
Tuberculosis, Allergy, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system
Epilepsy, stroke, dizziness, headache, paralysis or disorder of the brain or spinal cord
Disorder of the eyes, ears, nose or throat
Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorder or counseling for personal or work issues
Chronic Fatigue Syndrome, Epstein Barr virus or Lyme disease
Treatment for drug or alcohol abuse or use of any controlled substance
Has your client been rated, declined or offered modified coverage from any life or health insurance carrier
In the last 5 years has your client visited a physician, clinic or medical practitioner for treatment of any disease or disorder or been advised to begin any treatment program?
Details:

Please enter details for
any box checked

 Employment 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 the percentage of ownership, how long the prospect has owned the business, number of employees, etc.?  This is IMPORTANT for obtaining the best occupation class possible
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
Would you like a proposal for Disability Buy Sell coverage?
 Yes No
If yes, provide the value of the business:
Buy Sell Trigger Point:
Lump Sum:
 Yes No
Monthly Funding:
Yes No
 

 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: Most Recent/Current:
Last Complete Tax Year:
Bonus: Most Recent/Current:
Last Complete Tax Year:
Commission: Most Recent/Current:
Last Complete Tax Year:
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

 Other Coverage Information:
Does the prospect have ANY other disability benefits (including Group STD or LTD)? Yes No
If yes, Details including taxability of the benefit,benefits maximums, elimination period, etc.
 
 Illustration:
 

Desired Illustration Information
(Not all carriers provide all benefits or options or make them available to all risk classes - we will attempt to match your quote as closely as possible to your request)
Short Term Disability  

Elimination Period:

14 Days 30 Days 60 Days 90 Days

Benefit Period:

3 Months 6 Months 12 Months 24 Months

Product Requested :

Accident Only Accident & Sickness
Long Term Disability  

Elimination Period:

30 Days 60 Days 90 Days
180 Days 365 Days 730 Days

Benefit Period:

6 Months 12 Months 2 Years
5 Years 10 Years To Age 65
Age 67 Age 70 Lifetime

Own Occupation Period:

2 Years 5 Years Age 65
Age 67 Age 70 Lifetime

 Optional Provisions:

(Not all riders are available on all products)

Retirement Protection Benefits
Transitional Your Occupation
Own Specialty Your Occupation
Cola(Minimum) Cola(Maximum)
Residual 24 Months Residual Age 65
Partial
Future Increase Option
Automatic Increase Rider
Treatment of Injuries or Hospital Benefits
Group Replacement/Supplement Rider
Return of Premium
Catastrophic/ADL Rider
Social Insurance Offset Rider
Long Term Care Guaranteed Purchase Rider
 
Special Instructions:
 
 Additional Information
 
Please provide all additional information which may assist in generating an accurate illustration. Include information such as special travel, avocations or hobbies, special work circumstances or history, etc.

 
 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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