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Agent Infomation
Name
*
First
Last
Phone
*
Email
*
Date of Appointment
Date Format: MM slash DD slash YYYY
Client Information
Name
First
Last
DOB / Age
Gender / Sex
State
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
Reported Annual Income
Mark One
W-2
S Corp
C Corp
Specific Job Duties
Business Owner
Yes
No
Work From Home
Yes
No
Years of Ownership
Percentage of Ownership
Number of Employees
2 or More Years Profitability
Yes
No
% of Time doing Manual Duties
Bonus Income
Additional Income
Other DI In-Force
Group
Taxable
Intergrated
Monthly Benefit Cap
Percentage of Salary
PRODUCT PARAMETERS
Carrier Preference
Best for my Client Profile
Assurity
Illinois Mutual
Mutual of Omaha
Principal Financial Group
The Standard
Mass Mutual
Lloyd’s of London
Elimination Period
0 day
30 day
60 day
90 day
180 day
365 day
Benefit Period
1 Yr
2 Yr
5 Yr
To 65
To 67
To 70
Benefit Amount
Riders
COLA
Return of Premium
Own Occupation
Future Purchase Option
Residual Benefit
Catastrophic Disability
MEDICAL INFORMATION
Height
Weight
High Blood Pressure
Yes
No
Heart Disease
Yes
No
Circulatory Conditions
Yes
No
Blood / Protein in Urine
Yes
No
Mental / Nervous Condition
Yes
No
Bones / Joints / Skin
Yes
No
Fatigue
Yes
No
Stress
Yes
No
Anxiety
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Back / Neck
Yes
No
Thyroid
Yes
No
Cancer
Yes
No
Tumors
Yes
No
Cyst
Yes
No
Asthma
Yes
No
Respiratory
Yes
No
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