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Disability Income Insurance Illustration Request Form
CLIENT INFORMATION
Client Name
*
State of Residence
*
Date of Birth
*
+
Gender
*
Male
Female
Tobacco User
*
Yes
No
Job Title
Job Description / Duties
*
Self Employed NET profit (after expenses) = $
Business Owner
*
Yes
No
C-Corp
Yes
No
Number of Employees
Number of years in business
Premium Information
Employer Pay
Employee Pay
Pays into state DI?
Group LTD in force?
Yes
No
Monthly Amount $
To remain in force?
Yes
No
INDIVIDUAL DISABILITY POLICY
Monthly Benefit $ or maximum allowable
Elimination Period
30
60
90
180
365
Benefit Period
2 Years
5 Years
To Age 65
Benefit Riders SSIB
Benefit Riders
Residual Benefits
COLA
Non-Cancelable (may not be available)
Return of Premium
Own Occ. rider
Future Purchase Option
OVERHEAD EXPENSE POLICY
Monthly Benefits $
Elimination Period
30 days
60 days
90 days
Benefit Period
12 months
18 months
24 months
Benefit Riders: (if available)
Residual Benefits
Future Purchase Option
Return of Permium
DISABILITY INSURANCE Confidential Pre-Screening Questionnaire
Name
*
Date of Birth
*
+
Gender
*
Male
Female
Medical History
Have you smoked a cigarette or used a nicotine patch, gum or inhaler within the past 12 months? Please list date if yes.
Date
+
Never
.
What is your height and weight?
Are you currently taking any medication?
Yes
No
Are you pregnant?
Yes
No
Are you pregnant?
Yes
No
Do you have history of?
Neck or back disorders
Yes
No
Mental / Nervous conditions?
Yes
No
Depression / Anxiety?
Yes
No
In the last 5 years, have you seen any:
Physicians
Yes
No
Chiropractors?
Yes
No
Counselors / Psychiatrists?
Yes
No
If you answered yes to any of the above, please provide full details below:
Please provide details below of any other material medical history not disclosed above:
OTHER DISABILITY INCOME INSURANCE:
Do you have any Group Disability Insurance?
Yes
No
Do you have any Individual Disability Insurance?
Yes
No
Do you have any Association Disability Insurance?
Yes
No
If self-employed: Are you covered under the state disability insurance plan?
Yes
No
If you answered yes to any of the above, please provide full details below (amount, elimination period, and benefit period):
OCCUPATION
Occupational duties and approximate % time spent on each duty:
Time at current employer
Number of employees
Number supervised
Do you work from home?
Yes
No
Are you a Federal, State or City Employee?
Yes
No
Are you self-employed (file tax schedule C)?
Yes
No
If yes, please check:
Sole proprietor
C-Corp
S-Corp
LLC
LLP
(CA only) Do you contribute to California SDI?
Yes
No
Details to any of the above:
FINANCIAL
Gross Earnings (Adjusted gross earnings [AGI]) Approximate
Current year to Date $
Last Year $
2 Years ago $
Is your net worth greater than $6,000,000?
Yes
No
Unearned income (rentals, dividends, interest) $ (Type None if not received)
Did you receive any bonuses in the last 3 years?
Yes
No
Are you a permanent resident/citizen of the United States?
Yes
No
If you answered yes to any of the above, please provide details below (actual net worth, actual unearned income, sources, amount of bonus each year, etc.):
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