Disability Income Insurance Quote Request
Agent Information:

Agent name:

Phone number:

E-mail:


Client Information (basic):

Client name (important):

Client date of birth or age:

Client gender:

Client resident state:


Client Information (health history):

Client's build?

Has your client use tobacco products in the last 12 months?

Please list any health conditions, medications, dosages and/or hospitalizations in the past 10 years:







Client Information (occupation):

Client's employment status?

Client's occupation and daily work duties?



If client is an owner/manager/supervisor: (% office time, field supervising or doing manual labor)



If client is a physician: (list board certifications, specialties, or if a resident physician )




How long has your client been at their current position? 

Client's annual income?- W2 employee gross income:

- Self employed net income:


Client Information (current coverage):

Does your client currently have Disability Insurance?




If yes, what are the coverage parameters?
- Carrier name?

- Monthly benefit?

- Benefit period?

- Elimination period?

- Riders?

- Premium?

Does your client's benefit coordinate with Social Security? 

Are you looking to replace this coverage? 


Illustration (Quote) Design:

What type of Disability Insurance product quote do you need?




Desired monthly benefit? 


Desired benefit period? 
(note: all quotes will include an alternative benefits page that will show available benefit periods)

Desired elimination period?
(note: all quotes will include an alternative benefits page that will show available elimination periods)

Desired Riders?
(note: all quotes will include an alternative benefits page that will show available riders and their cost)

















What type of contract do you want?

Would you like a Life Insurance or Critical Insurance quote as well for your client? 


If so, what would you like to see quoted:




You're almost done!  Once you have answered the required questions above, click the "Submit Form" button to send us your request.  We will email your quote shortly!






MaleFemale
W-2Self-Employed
YesNo
YesNo
YesNo
Maximum Available

1 Year2 Years5 Years10 YearsTo Age 65To Age 67
30 Days60 Days90 Days180 Days365 Days
Guaranteed RenewableNon-Cancellable
Yes (Individual Plan)
Yes (Group Plan)
No
Unsure
Personal (Individual)
Business Overhead Expense
Guaranteed Standard Issue
Worksite/Group
5 year (if available)
10 year (if available)
To age 65 (not working) (if available)
True Own Occ To Age 65 (if available)
Future Increase Option (FIO)?
Own Occupation (if yes, select desired length)
(COLA) Inflation Protection
Residual Benefit
Retroactive Injury
Return of Premium (most companies don't have)
Yes
No
If unsure, is your client overweight?
YesNo