Client’s Name:
Client’s DOB:
State of Residence:
Gender: MaleFemale
Tobacco Use? YesNo
Occupation:
Title/Duties:
Benefit Period: 2 years5 yearsto age 65to age 67to age 70Lifetime
Elimination Period (days): 6090180365
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? YesNo
Replacement Percentage:
Benefit Group LTD Cap: $
Benefit Amount: $
Is there Individual Disability Income coverage? YesNo
Any health problems? Currently on any medications or counseling? Height weight ratio? Any special notes?
Producer’s Name:
Phone:
Email:
