Individual Long Term Disability/ Business Overhead

Producer Information

Producer Name:*

First Last

Producer Company Name:*

Address*

Street Address Address Line 2 City State ZIP Code

Phone:*

Fax

Email:

Producer Broker Dealer or National Account Affiliation:

Send proposal to:

Client Information

Name*

First Last

Date of Birth*

State Lives*

State Works*

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*

If less than 1 full tax year in business:

Former Occupation/Duties

Former Salary

Individual Case Design

Requested Benefit Amount

Max

Elimination Period

Benefit Period

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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Individual Long Term Disability/ Business Overhead

Capitas - Individual Long Term Disability/ Business Overhead

Producer Information

Client Information

Individual Case Design

Business Overhead Expense Case Design

Coverage InForce