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Disability
Insurance Proposal request form:
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Broker's Name:
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Broker's e-mail address:
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Mailing address:
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Fax number:
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Phone number:
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Delivery method:
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If pick up, date & time:
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Please refer this quote to:
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National Account Affiliation
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State proposed insured is from:
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State policy to be written:
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Proposed Insured's Name:
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Date of birth:
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Sex:
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male
female
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Tobacco last used:
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Type of tobacco:
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If cigars, how many used per week?:
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Does person work at least 30 hours per week?
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yes
no
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Medical conditions/medications:
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Nature of Occupation:
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Title:
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Percent of time performing manual duties:
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Percent of time supervising manual duties:
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Percent of selling time:
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Percent of time administrative:
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Employees in firm:
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Income (W-2):
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Bonuses for past 3 years:
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Is client an owner/self-employed?
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yes
no
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How long owner/self-employed?
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Net income in last full year:
(net income is gross income less expenses
but before taxes)
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Does person work out of home:
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yes
no
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What % of time does person leave home to conduct business:
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How long have they been working out of the home:
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Coverage in force:
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Group or individual:
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group
individual
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If group, what % does employee pay?
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%
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If group, what is the maximum cap?
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Amount of benefit(s) desired:
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Benefit Period:
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Elimination Period
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Riders, COLA, OWN OCC, NON-CAN, FPO, RESIDUAL, RECOVERY
BENEFIT, if available:
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If FPO, what amount:
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If recovery with principal, one year or three years? |
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Has there been a premium budgeted? |
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Other: |
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