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    Client’s Name:
    Client’s DOB:
    State of Residence:
    Gender:
    Tobacco Use?
    Occupation:
    Title/Duties:
    Benefit Period:
    Elimination Period (days):
    Current Year Income: $
    Income 2 years ago: $
    If business owner, how long?
    Percentage of manual duties:
    If less than one full tax year in business:
    Former Occupation/Duties:
    Former Salary: $
    Coverage In Force (fill all appropriate fields)
    Is there Group LTD?
    Replacement Percentage:
    Benefit Group LTD Cap: $
    Benefit Amount: $
    Is there Individual Disability Income coverage?

    Any health problems? Currently on any medications or counseling? Height weight ratio? Any special notes?

    Producer’s Name:
    Phone:
    Email: