Short Term Disability Quote Request

Agent Name:*

Agent Company:

Agent Email:*

Agent Phone:

Is this a 50/50 case?

Yes
No

Please choose the OCI Sales Executive helping you with this case:*

Client Phone Number:

Client Email:

Insured Name:

Date of Birth:

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

Elimination Period:

Benefit Period:

Desired Monthly Benefit Amount:

Premium Mode:

Optional Benefits/Riders

Critical Illness?

Yes
No

Hospital Confinement Indemnity?

Yes
No

Accident Medical Expense?

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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