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Individual Long Term Disability/ Business Overhead
Capitas - Individual Long Term Disability/ Business Overhead
Producer Information
Producer Name:
*
First
Last
Producer Company Name:
*
Address
*
Street Address
Address Line 2
City
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
State
ZIP Code
Phone:
*
Fax
Email:
Producer Broker Dealer or National Account Affiliation:
Send proposal to:
Client Information
Name
*
First
Last
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
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5
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31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
State Lives
*
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
State Works
*
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
Gender
*
Male
Female
Tobacco Use?
*
Yes
No
Occupation
*
Title
*
Duties
*
Years in Current Position
*
Work From Home?
*
Yes
No
If yes, % of time working at home:
Annual Income
*
(Net Income if Business Owner or Salary if Employee)
Bonus
*
Unearned
Self-Employed or Business Owner
*
Yes
No
Years in Operation
*
% of Ownership
*
Number of full time employees:
*
Type of Business
*
Sole Proprietor
S-Corp
C-Corp
Partnership
LLC
LLP
Sole
If less than 1 full tax year in business:
Former Occupation/Duties
Former Salary
Individual 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
Own Occupation
Residual/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
Premium Payor
Employee
Employer
Business Overhead Expense Case Design
Monthly Expenses
Requested Benefit Amount
Max
Elimination Period
30 Days
60 Days
90 Days
Benefit Period
12 Months
18 Months
24 Months
Optional Riders
Residential/Partial
Professional Replacement
Future Purchase Option
Return of Premium
In force BOE Coverage Amount
Coverage InForce
(Check all appropriate boxes)
Is there Group LTD coverage in force?
Yes
No
Replacement Percentage
Benefit Cap or Maximum
Elimination Period
Benefit Period
GLTD Coverage Employee %
GLTD Coverage Employer %
Taxable Benefits
Yes
No
Income Covered
Salary
Overtime
Bonus
Commissions
(Check all that apply)
Is there Individual disability coverage in force?
Yes
No
Individual DI Carrier
Benefit Amount
Elimination Period
Benefit Period
Individual Coverage Employee %
Individual Coverage Employer %
Taxable Benefits
Yes
No
Is there competition on the case? If Yes, provide details.
Medical Complications?
Past 5 years. Medications taking? Height & Weight?
I would like my proposal sent via...
*
Email
Overnight
Regular Mail
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