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Client Information

Name:

Date of Birth or Age:

Sex:

MaleFemale

State:

Tobacco:

Non-smokerSmokerChew TobaccoCigar

Occupation:

Include % of time & where they are performing their duties. If management, how many people do they manage.

Daily Duties:

Business Owner:

YesNo

After business expenses & before taxes

Income:

Existing Coverage

None:

Individual Amount:

Employee payEmployer Pay

Group LTD% of Income:

Monthly Cap:

Employee payEmployer Pay

Include all treaments, medications, conditions and dates

Medical Conditions:

Disability Income

Benefit Amount:

Maximum Available

Elimination Period:

30 Days60 Days90 Days180 Days365 Days730 Days

Benefit Period:

1 year2 years5 years10 yearsAge 65Age 67Age 70

Definition of Disability:

Best AvailableOwn OccupationTransitional Occupation

Optional Benefits:

CatastrophicCritical IllnessResidual
Cost of Living AdjustmentFuture Increase OptionSocial Insurance
Other:

Comments:

Business Overhead Expense

Benefit Amount:

Maximum Available

Elimination Period:

30 Days60 Days90 Days

Benefit Period:

12 Months15 Months18 Months24 Months30 Months

Optional Benefits:

ResidualFuture InsurabilitySalary Replacement

Comments:

Disability Buyout

Benefit Amount:

Maximum Available

Elimination Period:

12 Months18 Months24 Months

Benefit Period:

Lump Sum24 Months36 Months60 Months

Comments:

Key Person Disability

Benefit Amount:

Maximum Available

Benefit Period:

Lump SumLump Sum with Monthly

Monthly Elimination Period:

90 days180 days

Lump Sum Elimination Period:

180 days365 days730 days

Comments:

Disability Retirement Protection

Benefit Amount:

Maximum Available

Elimination Period:

180 days365 days

Benefit Period:

Age 65Age 67

Optional Benefits:

Automatic IncreaseCola 3%Cola 6%

Comments:

Business Loan Protection:

Total Amount of Loan:

Monthly Loan Payment:

Effective Date:

Termination Date:

Comments:

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