Toll Free: 866-METRO77
Home
About Us
Why Join MetroDI?
Our Team
Our History
News
Sales Tools
Products
Individual Disability Income
Business Overhead Expense
Business Loan Protection
Disability Buy-Out
Retirement Income Replacement
Key Person Disability Insurance
Impaired Risk
Specialty Coverage
Guaranteed and Simplified Issue Plans
Carrier Overview
Highlights & Policy Features
Ameritas Life
Assurity Life
Fidelity Security Life
Petersen International
Principal Financial Group
The Standard
Definitions of Disability
Basic Disability Insurance Concepts
Marketing Materials
Ameritas Life
Assurity Life
Fidelity Security Life
Petersen International
Principal Financial Group
The Standard
Disability Insurance Statistics
Request a Quote
Metro DI
Underwriting
The Process
Medical Underwriting
Financial Underwriting
Forms & Documents
Applications
Contracting
Forms
Contact Us
Request A Quote
Home
Request a Quote
Print Page
Email Page
Request a Quote
Agent Information
Agent:
Phone:
-
Cell:
-
Email:
Client Info
Disability Income
Business Overhead
Disability Buyout
Key Person
Disability Retirement
Business Loan Protection
Client Information
Name:
Date of Birth or Age:
Sex:
Male
Female
State:
--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Tobacco:
Non-smoker
Smoker
Chew Tobacco
Cigar
Occupation:
Include % of time & where they are performing their duties. If management, how many people do they manage.
Daily Duties:
Business Owner:
Yes
No
Length of Time Owned:
Number of Employees:
Type of Business Entity:
--Select--
Sole Proprietor
Partnership
Sub S Corp
C Corp
LLC
LLP
After business expenses & before taxes
Income:
Existing Coverage
None:
Individual Amount:
Employee pay
Employer Pay
Group LTD% of Income:
Monthly Cap:
Employee pay
Employer Pay
Include all treaments, medications, conditions and dates
Medical Conditions:
Disability Income
Benefit Amount:
Maximum Available
Elimination Period:
30 Days
60 Days
90 Days
180 Days
365 Days
730 Days
Benefit Period:
1 year
2 years
5 years
10 years
Age 65
Age 67
Age 70
Definition of Disability:
Best Available
Own Occupation
Transitional Occupation
Optional Benefits:
Catastrophic
Critical Illness
Residual
Cost of Living Adjustment
Future Increase Option
Social Insurance
Other:
Comments:
Business Overhead Expense
Benefit Amount:
Maximum Available
Elimination Period:
30 Days
60 Days
90 Days
Benefit Period:
12 Months
15 Months
18 Months
24 Months
30 Months
Optional Benefits:
Residual
Future Insurability
Salary Replacement
Comments:
Disability Buyout
Benefit Amount:
Maximum Available
Elimination Period:
12 Months
18 Months
24 Months
Benefit Period:
Lump Sum
24 Months
36 Months
60 Months
Comments:
Key Person Disability
Benefit Amount:
Maximum Available
Benefit Period:
Lump Sum
Lump Sum with Monthly
Monthly Elimination Period:
90 days
180 days
Lump Sum Elimination Period:
180 days
365 days
730 days
Comments:
Disability Retirement Protection
Benefit Amount:
Maximum Available
Elimination Period:
180 days
365 days
Benefit Period:
Age 65
Age 67
Optional Benefits:
Automatic Increase
Cola 3%
Cola 6%
Comments:
Business Loan Protection:
Total Amount of Loan:
Monthly Loan Payment:
Effective Date:
Termination Date:
Comments: