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Multi-Life Offer Request Form
Capitas - Multi-Life Offer Request Form
Producer Information
Please Note: a Census Form is Required to Complete This Proposal Request
Download the Excel spreadsheet census form by
clicking here
.
You may attach the completed Excel file at the bottom of this form.
Producer Name:
*
First
Last
Producer Company Name:
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone:
*
Fax
Email:
*
Producer Broker Dealer or National Account Affiliation:
*
Send proposal to:
Case Information
Case Name
*
Date by Which Offer is Needed
*
MM slash DD slash YYYY
Effective Date of Coverage
*
MM slash DD slash YYYY
Main Location City
*
Main Location State
*
Other Locations and States
*
How long has this business been in operation?
*
Nature of Business
*
Type of Entity
C-Corp
S-Corp
Partnership
LLC
LLP
Total Number of Employees
*
Number to be Considered for Offer
*
SIC#
Occupations (Nature of 'ee group) to be Considered
*
Premium Payer
Employer Percentage
*
Employee Percentage
*
Proposed DI Effective Date
*
MM slash DD slash YYYY
Multilife Case Design
Requested Benefit Amount
Max
Elimination Period
14 Days
30 Days
60 Days
90 Days
180 Days
365 Days
720 Days
Benefit Period
6 Months
1 Year
2 Years
5 Years
10 Years
To Age 65
To Age 67
To Age 70
Lifetime
Optional Riders
Residential/Partial
Cost of Living Adjustment
Catastrophic Benefit
Future Purchase Option
Automatic Increase Option
Recovery Benefit
Return of Premium
Retirement Completion Product
Yes
No
Retirement Plan Income Deferral
Premium
Level
Step Rate
Coverage InForce
Check all that apply:
Individual
Group LTD
Combination
None
Group LTD
Carrier Name
Replacement Percentage
Benefit Maximum
Taxable?
Taxable Benefit
Non-Taxable Benefit
Income Covered
Salary
Overtime
Bonus
Commissions
Pension Contributions
(Check all that apply)
Elimination Period
14 Days
30 Days
60 Days
90 Days
180 Days
365 Days
720 Days
Benefit Period
6 Months
1 Year
2 Years
5 Years
10 Years
To Age 65
To Age 67
To Age 70
Lifetime
Individual DI
Benefit Amount
Elimination Period
14 Days
30 Days
60 Days
90 Days
180 Days
365 Days
720 Days
Benefit Period
6 Months
1 Year
2 Years
5 Years
10 Years
To Age 65
To Age 67
To Age 70
Lifetime
Taxable?
Taxable Benefit
Non-Taxable Benefit
Other Information
Is there competition on the case?
Yes
No
If Yes, provide details.
Are you aware of any individuals listed on the census that have a significant medical history?
Any special considerations we should be aware of?
Your marketing plans are important to our consideration of an offer. Describe how this offer will be communicated to all employees:
Census Form
Upload Excel Census Form (You may also email the census to
[email protected]
.)
Accepted file types: xls, xlsx, Max. file size: 20 MB.
Don't have the Excel file?
Download our pre-formatted Excel spreadsheet census form by
clicking here
.
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