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Search for:
Long Term Disability Quote
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Long Term Disability Quote
Long Term Disability Quote
Agent Name:
*
Agent Company:
Agent Email:
*
Agent Phone:
Is this a 50/50 case?
Yes
No
Client Phone Number:
Client Email:
Insured Name:
Date of Birth:
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:
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
Plan Design
Type:
Non-Cancelable
Guaranteed Renewable
Elimination Period:
30 days
60 days
90 days
180 days
Benefit Period:
2 year
5 year
10 year
To age 65/67
Maximum Available
Desired Monthly Benefit Amount:
Desired Monthly Premium Amount:
Premium Mode:
Annual
Semi-Annual
Quarterly
Monthly
Optional Benefits/Riders
Inflation?
Yes
No
Guaranteed Insurability Option?
Yes
No
Catastrophic?
Yes
No
Residual Disability Benefit?
Yes
No
Pure Own Occ?
Yes
No
Additional comments, health concerns, or medications?
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.
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