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Disability Quote

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Agent Name:*
Agent Company:
Agent Email:*
Agent Phone:*
Disability Income plans typically cost 2-3% of client’s total income. Have you discussed this with your client?
- Yes
- No
Please discuss this with your client before requesting a quote.

We encourage you to schedule a call with one of OCI’s DI Planning Specialists before proceeding any further. Please click the link below to schedule a call:
https://oci.appointlet.com/b/dan-dahl
https://oci.appointlet.com/b/joe-gordon
Insured Name:*
Date of Birth:*
Date Format: MM slash DD slash YYYY
Height & Weight:*
Gender:*
- Male
- Female
State:*
Tobacco User?*
- Yes
- No
Annual Gross Income:*
Existing Group Coverage?*
- Yes
- No
% of Salary Covered:*
Monthly Benefit Cap:*
Occupation and Duties (More specific the better - please note if insured is government/state employee):*
Business Owner (at least 20% and owned business for at least 2+ years)?*
- Yes
- No
Is the individual self-employed?*
- Yes
- No
Is the individual a W-2 employee?*
- Yes
- No
Plan Design
Note: Individual DI coverage does not cover pregnancy.
Elimination Period:*
Elimination Period:*
Benefit Period:*
Benefit Period:*
Desired Monthly Premium Amount:*
Premium Mode:*
Benefit Amount*
Additional comments, health concerns, or medications? Note: Individual Disability insurance does NOT cover maternity leave.
VERY IMPORTANT: Over 40% of disability cases are rated, declined, or carry exclusions. Eliminate the surprise for your client and increase your closing percentage by asking your client about any known health conditions. Specifically ask if they have a history of neck or back disorders, diabetes, cardiac conditions, depression/anxiety, sleep apnea, or cancer.
By clicking Submit, I certify all information is true and accurate to the best of my knowledge.

About Us

Headquartered in Omaha, Neb., OCI Insurance & Financial Services, Inc., is an insurance and employee benefits general agency. The company provides support to thousands of agents nationwide in the placement of these products and services.

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402.330.8700
Toll free: 866.320.8700
Fax: 402.330.8706

4221 N. 203rd St, Ste 200
Elkhorn, NE 68022

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Friday: 8:00 am – 4:30 pm

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