Get DI Quote 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:
