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Disability Insurance Quote
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Disability Insurance Quote Request
Request a Disability Insurance Quote
Step 1 of 3 - Agent Information
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Agent Information
Name
*
Phone
Fax
Email
*
Client Information
Name
*
Date of Birth
*
Month
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1928
1927
1926
1925
1924
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1922
1921
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Gender
*
Male
Female
State of Residence
*
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Marital Status
*
Single
Married
Domestic Partner
Widowed
Divorced
Tobacco Use
*
Yes
No
Medical Information
Height
Weight
Medications and Dosages
In the last five years, has your client been treated for or received medical advice?
List details above
Employment Information
Occupation
Job Duties
Length of Employement
Works from home?
No
Yes
Work at home details
Owns their own business?
No
Yes
How many years have they owned their business?
How many employees?
Income Information
Income after business expenses but before taxes
Annual Salary
Bonus
Commission
Has bonus/commission been consistent for the past three years?
Yes
No
Please explain inconsistent commission
enter details here
Other Coverage Information
Does the client have any other disability benefits (including Std or Ltd)?
If yes, please list details including taxability of the benefit, benefit maximums, elmination period, etc.
Illustration Information
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
Own Occupation Period
2 Years
5 Years
Age 65
Age 67
Age 70
Lifetime
Would you like a proposal for Business Overhead Expense (BOE) coverage?
No
Yes
BOE Details
Please enter any details such as proposed insured's share of the monthly expenses.
Would you like a proposal for Buy Sell coverage?
No
Yes
Buy/Sell Coverage Details
Please list Buy/Sell coverage details including business value, trigger point, lump sum and monthly funding.
Would you like information on the FamilyGuard product?
No
Yes
FamilyGuard 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.)
Number of Children
0
1
2
3
4
5
6
7
8
9
10
Level of Education
None
Daycare
Private School
College
Monthly Cost of Education
Optional Provisions
Own Occupation
Modified Own Occupation
Cola(Minimum) after 12 mos of paid disability
Cola(Maximum) after 12 month of paid disability
Residual/Partial
Future Increase Option
Group Replacement/Supplement Rider
Return of Premium
Catastrophic/ADL Rider
Social Insurance Offset Rider
(not all riders are available on all products)
Special Instructions
Would you like us to suggest the one carrier we feel provides the best value for your client?
Yes
No
Enter the characters you see below
Long Term Care Quote Request
Request a Long Term Care Quote
Step 1 of 3 - Agent Information
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Agent Information
Name
*
Phone
Fax
Email
*
Client #1 Information
Client #1: Name
*
Client #1: Date of Birth
*
Month
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Year
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2020
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1951
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Client #1: Gender
*
Male
Female
Client #1: State of Residence
*
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Client #1: Marital Status
*
Single
Married
Domestic Partner
Widowed
Divorced
Client #1: Tobacco Use
*
Yes
No
Medical Information
Client #1: Medications and Dosages
Client #1: Medical History
List details above
Client #1: Underwriting Class Requested
Preferred
Standard
Client #1: Height
Client #1: Weight
Client #1: Has this client applied for, been issued or been declined for LTCi in the past?
Yes
No
Client #1: Details
Client #2 Information
Client #2: Name
*
Client #2: Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
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30
31
Year
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Client #2: Gender
*
Male
Female
Client #2: State of Residence
*
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Client #2: Marital Status
*
Single
Married
Domestic Partner
Widowed
Divorced
Client #2: Tobacco Use
*
Yes
No
Medical Information
Client #2: Medications and Dosages
Client #2: Medical History
List details above
Client #2: Underwriting Class Requested
Preferred
Standard
Client #2: Height
Client #2: Weight
Client #2: Has this client applied for, been issued or been declined for LTCi in the past?
Yes
No
Client #2: Details
Illustration Information
Coverage Requested
Reimbursement
Indemnity
Cash
State of Policy Issue
Benefit Period
1
2
3
4
5
6
7
8
9
10
Benefit Amount
Benefit Design
Monthly
Daily
Home Health Care
0%
50%
75%
100%
Elimination Period
0 Days
20/30 Days
50/60 Days
90/100 Days
180 Days
365 Days
Inflation Riders
None
CPI
Simple
Compound 3
Compound 5
Additional Riders
Shared Care
Return of Premium
Restoration of Benefits
Waiver of Premium
Uninsurable Spouse
Survivorship
Zero Day EP for Home Care
Other
Regular Payment Modes
Annual
Semi-Annual
Quarterly
Monthly
Limited Payment Plans
10 Pay Premium
20 Pay Premium
Paid up at age 65
Is this a partnership case?
Yes
No
Special Instructions
Attached any relevant documents below
Accepted file types: png, pdf, jpg, doc, docx, ppt, pptx.
Would you like us to suggest the one carrier we feel provides the best value for your client?
Yes
No
Enter the characters you see below
Quote Request Form for Printing/Faxing
Download a Disability Insurance Quote Form
Download a Long Term Care Insurance Quote Form
