DISABILITY QUOTE
  Producer Name:
  Email:
  Phone Number:
  Client:
  State:                  Male  Female
  Client Date of Birth: //  or  Age:
  Annual Income:      Government Employee: Yes  No
  Occupation Title and all duties:
  Client Tobacco: Yes  No      Client Height/Weight:
  Health Problems/Medications:
  Does client own >= 25% of the business Yes  No
  If yes, please answer the following:
  Years Owned::     Number of full-time employees:
  Is office in home: Yes  No
  % of time spent in home:
  Business type: Sole Prop Partner S-Corp C-Corp LLC
 
 

Is there any other coverage to remain in force? Yes  No 

If yes, please indicate type of coverage
  Group short term disability? Yes  No Benefit Amount:
  Group long term disability? Yes  No Taxable Benefit? Yes  No
  Personal disability policy? Yes  No Benefit Period:
 
  Benefit Period: 2 Yrs 3 Yrs 5 Yrs To Age 65
To Age 67 To Age 70 Lifetime
  Waiting Period:
 
  		Benefit Amount $
                               OR   MAX
  Riders:
 		 Social Insurance FIO COLA Catastrophic
LTC Purchase Option
Other:
 
  Company Preference: The Standard Illinois Mutual Assurity
Guardian (available only in AL, GA, FL, NC, SC, TN) MetLife 
Principal
  Receive Quote by: Mail Fax Email
  Additional Comments: