Skip to content
Call Us: 402.330.8700
Home
Who we are
What We Do
Individual Health
Group Health
Split Cases/Client Referral
Medicare
Life, Disability, LTC, Annuities
Resources
OCI Symposium
Beverage Break Video Podcast
Webinars
Circle of Excellence Incentive Program
Agent Bonus Programs
Compensation Disclosure
Our Staff
Join Our Team
Administration
Finance
Financial Solutions
Group
Individual
IT
Contracting
Marketing
Officers
Partner With Us
Login
Search for:
Short Term Disability Quote Request
Home
/
Short Term Disability Quote Request
Short Term Disability Quote
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:
*
Aaron Clark
DC Couch
Not yet working with one of the above.
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
Elimination Period:
0 days
7 days
14 days
30 days
60 days
90 days
Benefit Period:
3 months
6 months
1 year
2 years
Desired Monthly Benefit Amount:
Premium Mode:
Annual
Semi-Annual
Quarterly
Monthly
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.
CAPTCHA
