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: