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
Date of Birth
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 $
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
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
Monthly Expenses
Elimination Period 30 Days 60 Days 90 Days
Benefit Factor 12 Times 18 Times 24 Times
Business Value
Percent of Ownership
Elimination Period 365 Days 540 Days 730 Days
Payment Method Lump Sum Monthly Installments Combination
Cost of Living
Benefit Increase
Residual Disability
Extended Benefit Period
Return To Work
Regular Occupation * all riders are not available in all occupation classes
Goal We Would Like To Meet
This Illustration Is Needed By:
I Would Like My Request Sent By:
Fax
Mail
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