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All fields marked with an asterisk are required.

Please indicate the types of insurance

Disability Insurance

Disability Insurance

Replaces lost personal income in the event of disability

Business Overhead

Business Overhead

Reimburses business expenses for small business owners

Buy/Sell

Buy/Sell

Funds buyout agreement for business owners

Retirement Protection

Retirement Protection

Replaces lost savings for retirement - usually in addition to regular DI limits

Key Person

Key Person

Disability insurance to protect owners from the loss of a key employee

Loan Indemnification

Loan Indemnification

Disability insurance policies that indemnify business loans

Long Term Care Insurance

Individual/Couple Long Term Care

Agent Information

Agent Name:*

Phone Number:*

Fax Number:

Address:

City:

State:*

Zip:

Email:*

Client Information

Client Name:*

Birthday:*

Gender*

Male
Female

Client is:*

Single
Married
Live-in (3yrs+)

State of Residence:*

Nicotine use in past 12 months?:*

Yes
No

Marijuana use in the past 12 months?*

Yes
No

Purpose of Use*

Medicinal
Recreational

How often is marijuana used?*

Health history / Medications & Dosage:*

College Degree:*

Yes
No

If yes, which degree (BA, MA, PhD, ect.)?:*

Income:*

Annual Premium Budget:

Occupation:*

Duties:*

Percentage of work performed from home:*

Is the prospect a business owner?:*

Yes
No

If business owner, which type?:*

C-Corp
S-Corp
Partnership
Sole Proprietor

Years in business:*

Number of employees:*

Disability Insurance Information

Name of Employer:

Premium Payer:*

Elimination Period:*

Benefit Period:*

Benefit Amount:*

Riders:

Residual
Future Purchase Option
COLA
Noncancelable
Social Offset
Own Occupation
Catastrophic Illness
Student Loan Repayment

Amount of existing coverage:

Group: $*

Individual: $*

Additional Comments:

(i.e. travel, hazardous activities, replacement of coverage, etc)

Business Overhead Information

Elimination Period:*

Benefit Period:*

Benefit Amount:*

Riders:

Residual
Salary Replacement
Purchase Future Option

Existing Coverage:*

Additional Comments:

(i.e. travel, hazardous activities, replacement of coverage, etc)

Buy / Sell Information

Total value of business $:*

Existing coverage $:*

Number of partners:*

% of ownership:*

Elimination Period:*

Benefit Payout:*

Benefit Amount:*

Riders:

Future Purchase Option

Additional Comments: (ie travel, hazardous activities, replacement of coverage, ect)

Retirement Protection

Premium Payor:*

Elimination Period:*

Benefit Period:*

Benefit Amount:*

Riders:

COLA
Future Purchase Option

Existing Retirement Protection?*

Yes
No

Individual disability benefit with lifetime benefit period?*

Yes
No

Additional Comments: (ie travel, hazardous activities, replacement of coverage, ect)

Key Person

Has existing coverage:*

Yes
No

Additional Comments: (ie travel, hazardous activities, replacement of coverage, ect)

Loan Indemnification

Principal Loan Amount:*

Monthly Payment Amount:*

Term of Loan (# of years):*

Has existing coverage:*

Yes
No

Additional Comments: (ie travel, hazardous activities, replacement of coverage, ect)

Individual/Couple Long Term Care

Daily Benefit: $*

Show as monthly benefit*

Yes
No

Home Care %:*

Benefit Period:*

Elimination Period:*

Inflation:*

Show limited pay option(s)if available?*

Payment Options:

Riders:

Zero day E.P homecare
Nonforfeiture
Shared Care
Survivorship
Return of Premium

Spouse's Name

First Last

Spouse's Gender

Male
Female

Spouse's Birthdate

Has your client had a complete medical exam, including labs, in the last 24 months?*

Yes
No

Does your client have problems with memory or other cognitive impairment? If so, please provide details:*

Does your client have a parent or sibling who has been / was diagnosed with dementia? If yes, please provide age of diagnosis?

Additional Notes:

Additional Information

Date Presenting:

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