Personal Information

*Name: Last, First & Middle Initial
*Address:
City: State: Zip:
*Home Phone: Best Time To Call:
Work Phone: Best Time To Call:
Fax:
*E-Mail:
Are you employed? yes no
Do you own your own company? yes no
Would you like to include coverage for your spouse? yes no

Disability Information

Have you ever smoked cigarettes or used any other forms of tobacco or nicotine?
Never Smoke cigarettes Use nicotine gum Quit less than 2 years ago Quit 2-3 years ago Quit 3-5 years ago Smoke pipe Smoke cigars Chew Tobacco

What is your occupation?

Please describe your job duties.

Are you a business owner? yes no

Ownership percentage? %

How long have you been an owner?

Number of employees?

Industry type? (e.g., health, construction, finance, etc.)

Business entity type: select one below C-Corp S-Corp LLC Partnership Sole Proprietor

Annual Income: Earned $ Bonus $ Unearned $

Premium Payer: Individual Employer

The Plan

Basic Monthly Benefit
Maximum available
% of Income
Specific Amount:

Elimination Period (days): 30 60 90 180 365

Benefit Period: 2 years 5 years to age 65

Your Occupation Period: 2 years 5 years to age 65

RIDERS

Automatic Benefit Increase: yes no
Guaranteed Insurability: yes no
Residual Disability Benefit: No Full Partial
COLA: none Simple Compound
Premium Refund Option: yes no
Regualr Occupation: yes no

EXISTING COVERAGE

Do you have any coverage in force now?

What is the benefit amount?

Is there a benefit cap?

Elimination Period (days): 30 60 90 180 365

Benefit Period: months or to age 65

Premium Payer: Individual Employer

DEFINITIONS

Disability.  Due to injury or illness, you are unable to perform the material and substantial duties of your regular occupation (Own-Occ) or any occupation (Any-Occ). Each company has its own definition of total disability.  Be sure to read both the illustration and the contract. 

Basic Monthly Benefit.  The monthly amount you will be paid should you become disabled.

 Elimination Period.  The number of days you must wait before benefits begin. 

 Benefit Period.  The length of time benefits will be paid – anywhere from 2 years to age 65.

 Automatic Increase.  If added to the policy, this rider increases your monthly benefit automatically for a certain number of years, usually the first five policy anniversaries. 

 Guaranteed Insurability.  This rider allows you to increase the monthly benefit amount on certain option dates, subject to financial underwriting. 

 Residual Benefits.  This rider takes effect after a period of total disability.  If you return to work but are prevented from performing one or more of your regular duties, you will be paid a benefit in proportion to your loss of income. 

COLA (Cost of Living Adjustment).  This rider allows the monthly benefit to increase annually but only after you have been on claim for 12 months.

 Return of Premium.  Premiums are refunded after a certain period of time.  Each company has its own return-of-premium policy and, usually, other conditions must be met. 

 Regular Occupation.  Purchasing this rider will actually change the definition of total disability from being unable to perform the duties of your regular occupation or any other job to simply being unable to perform the duties of your “own occ.”  Of course you must also be receiving care from a physician, unless this requirement is waived by the company.