Individual Long Term Disability/ Business Overhead

This form is for all Individual Long Term Proposals and all Business Overhead Expense cases.

Please complete the form below to submit your request.

* = Required Fields

Producer Information

Company Name, Broker Dealer, or National Account Affiliation:*

Occupational History

Number of full time employees:*

If Less Than 1 Full Year in Self Employment:

Former Occupation/Duties

Former Salary

(Past two years)

Duties in Current Position

Duties in Current Position*

Please include description and % of time, if any manual duties.

Years in Current Position*

Annual Income*

(NET Income if Business Owner/Self-Employed/1099)

Bonus / Commissions

(Need two year average)

Stock Options / RSUs

(Need three year average already paid to include)

Unearned Income

(Rental Income, Interest, Dividends, Capital Gains)

Individual Case Design

Coverage In Force

(All fields are required)

Replacement Percentage*

Monthly Benefit Cap*

Combo - % Employer Paid*

Combo - % Employee Paid*

Individual DI Carrier*

Combo - % Employer Paid*

Combo - % Employee Paid*

Business Overhead Expense Case Design

In force BOE Coverage Amount

Additional Information

Medical Complications?*

Past 5 years. Medications taking? Height & Weight?

Any special notes? Competition? Carrier preference?