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Resources
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Request a Quote

REQUEST A QUOTE

Send us the case. We'll do the rest.

Quotes and a client-ready presentation, same day, never more than 24 hours. You don’t need to be contracted to get a quote.

Disability Insurance Quote Request

1Agent Information

2Client Information

3Illustration Information

LinkedIn

This field is for validation purposes and should be left unchanged.

Agent Information

Agent Name(Required)

Email(Required)

Phone

Fax

About your client

Name(Required)

Date of Birth(Required)

MM

DD

YYYY

Gender(Required)

Male

Female

Tobacco Use(Required)

Yes

No

State of Residence(Required)

Marital Status(Required)

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

Length of Employement

Job Duties

Works from home?

No

Yes

Owns their own business?

No

Yes

Work at home details

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

Benefit Period

Own Occupation Period

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.

Buy/Sell Coverage Details

Please list Buy/Sell coverage details including business value, trigger point, lump sum and monthly funding.

Would you like a proposal for Buy Sell coverage?

No

Yes

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

Level of Education

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

Δ

Prefer to email it?

Download a quote form, fill it in, and send it to quotes@fsgbrokerage.com.

Disability Insurance Quote Form (PDF)

Long–Term Care Quote Form (PDF)

What comes back

Quotes from the carriers that fit, built into a presentation with your name on the cover.

See a sample presentation

Long Term Care Quote Request

Request a Long Term Care Quote

Step 1 of 3 - Agent Information

0%

Agent Information
Name*
Phone
Fax
Email*

Client #1 Information
Client #1: Name*
Client #1: Date of Birth*
MM
DD
YYYY
Client #1: Gender*
- Male
- Female
Client #1: State of Residence*
Client #1: Marital Status*
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*
MM
DD
YYYY
Client #2: Gender*
- Male
- Female
Client #2: State of Residence*
Client #2: Marital Status*
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
Benefit Amount
Benefit Design
- Monthly
- Daily
Home Health Care
Elimination Period
Inflation Riders
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
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, Max. file size: 8 MB.
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

Δ

Quote Request Form for Printing/Faxing

Download a Disability Insurance Quote Form

Download a Long Term Care Insurance Quote Form

Financial Solutions Group, Inc. (FSG) provides training, marketing support, and administrative back-office services for disability income, long-term care, and related insurance products.

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