Agent Information

          Name  

          Title  

          Business Name  

          check here to use address of record  

          Mailing Address  

          Address (cont.)  

          City  

          State  

          Zip Code  

          Work Phone  

          Fax Number  

          E-mail  

          check here to update your address of record  

Client Information

          Name  

          Date of Birth   (mm/dd/yyyy)

          Sex   Female Male

          Tobacco User   No Yes

          If Yes, Describe Usage  

          State of Residence  

          Occupation  

          Job Duties  

          (be specific & include percent of time spent on each duty)

         Current Salary   $

          (use Net Income if self-employed)

          Additional Income   $

          Unearned Income   $

Existing Disability Insurance

          Coverage   None Group Individual   IF your client has BOTH group and individual coverage, put one set of
                                                           info below and the other  in the Additional Information box below.

          Premium Paid By   Employee Employer

          Benefit Amount or Percent of Income  

          Monthly Cap  

          Elimination Period   30 Days 60 Days 90 Days 180 Days 365 Days Other   if other indicate how many days

          Benefit Period   2 Years 5 Years To Age 65

Benefit Options - Individual

          Basic Amount             SIS  

          Total Monthly Benefit  
          check here to request max base only  
          check here to request max base with SIS combination  

          Elimination Period   30 Days 60 Days 90 Days 180 Days 365 Days

          Benefit Period   2 Years 5 Years To Age 65

Benefit Options - Overhead Expense

          Monthly Expenses  

          Elimination Period   30 Days 60 Days 90 Days

          Benefit Factor   12 Times 18 Times 24 Times

Benefit Options - DI Buy-Out

          Business Value  

          Percent of Ownership  

          Elimination Period   365 Days 540 Days 730 Days

          Payment Method   Lump Sum Monthly Installments Combination

          Additional Riders*

                    Cost of Living      Benefit Increase      Residual Disability

                                 Extended Benefit Period          Return To Work

                                                      Regular Occupation
       
    * all riders are not available in all occupation classes

Additional Information / Special Instructions / Goal We Would Like To Meet

This Illustration Is Needed By:     (mm/dd/yyyy)

I Would Like My Request Sent By:

                  E-mail        Fax       Mail