Disability Quote Request a Disability Insurance Quote Step 1 of 2 50% Date MM slash DD slash YYYY Producer's Name First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Client NameSex Male Female Date of Birth MM slash DD slash YYYY Tobacco Yes No Type of TobaccoState where Client LivesState where app will be signedBusiness Owner or Self Employed? Yes No Percent OwnershipNumber of Years as OwnerType of Business Entity Sole Proprietorship Partnership S Corp C Corp Number of EmployeesHow old is the business?For W-2 Employees Private Sector Public Sector (Federal, State, County, Municipal, Local) How Many YearsPolicy Types Individual Disability Income Key-Person Replacement Business Overhead Expense Business Loan Protection Disability Buy Out Retirement Savings Protection Individual Disability IncomeDesired Monthly Amount or MaximumElimination Period (days) 30 60 90 180 365 730 Benefit Period 2 years 5 years Age 65 Age 67 Age 70 Lifetime (if available) Optional Riders Residual Future Purchase Option COLA Non-Can Other Please SpecifyBusiness Overhead ExpenseMonthly Amount(s)Elimination Period (days) 30 60 90 Benefit Period 12 months 18 months 24 months 30 months Optional Riders Residual Future Purchase Option Other Please SpecifyHas a certain premium been budgeted or planned?Special Requests? Questions for Pre-Screening Disability Insurance Products1. Describe the occupation and exact duties2. Where is the work preformed? Office, home, lab, in the field, client site, etc.3. Other activities, hobbies, or avocations that might be considered hazardous?Work related or recreational, i.e. SCUBA, racing, climbing, flying4. Is ratio of height and weight normal?5. Any significant medical history, chiropractic visits, or surgeries (past or planned)?6. Please list all medications you are currently taking:7. Any current or part treatment (medication &/or counseling) for depression, anxiety, stress, or any other mental/nervous history?8. Amount of taxable/earned/documented income reported on last year's tax return9. Is there any current group Long Term Disability (LTD) or any individual Disability Income (DI) in-force? Yes No How much monthly benefit of each?Do you want to replace current coverage? Yes No If yes, Show same amount Show maximum amount Do you want to show the additional amount, keeping current coverage? Yes No 10. Any other comments, underwriting concerns, or other details? Δ
