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:

Height & Weight:

Gender:

Male
Female

State:

Nicotine/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:

Benefit Period:

Desired Monthly Benefit Amount:

Desired Monthly Premium Amount:

Premium Mode:

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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