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Home > Disability Insurance > Disability Insurance Request For Proposal
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Disability Insurance Request For Proposal


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

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CONTACT INFORMATION
Date
/ /
Date of Birth
/ /
Gender
State of Residence
ZIP / Postal Code *
First Name *
Last Name *
Primary Phone Number *
E-Mail Address *
Employer or Company Name
How many hours/wk. Do you work?
Occupation Description: List the top 3 tasks you perform and provide a percentage of time spent on each.
Please list any advanced degrees or certifications
If you are an MD, are you in

Type of Employee

Financial Advisor’s Name
Advisor Email Address
Advisor Phone Number
FINANCIAL AND OTHER DISABILITY INSURANCE INFORMATION
What were your earnings from your profession last year? (approx.) (Gross income less business expenses, but before taxes, including your net K-1 earnings/loss from your occupation)
What is your base salary?
How much bonus/commission did you recieve?
What was income last year from dividends, interest, rents, royalties, estates, trusts? (approx.)
What is contributed to IRA, HR10, qualified pension or profit-sharing plan? (approx.)
Was this included in question #1?

Do you have group disability insurance through your employer?

Employer paid?

Is your bonus/commission income (if applicable) covered under your employer group disability policy?

What percentage of income is covered?
What is the max. benefit?
Do you own any individual disability insurance?
If yes, Insurance company
Monthly Benefit Amount
BUSINESS OWNER - COMPANY INFORMATION
How long have you owned your business?
What % of the business do you own?
How many partners do you have?
How many employees do you have?
Do you have an outstanding business loan?

If so, how much is the monthly payment?
Type of business entity?




HEALTH INFORMATION
Height
Weight
Change of weight in the last 12 months? (reason
Within the last 10 years, have you received treatment or been advised to seek treatment? (if yes please select for which)

If yes, amount, how often
Within the last 10 years, have you filed a claim for disability benefits?
Within the last 10 years, has any application submitted for accident, sickness, hospitalization, major medical or life insurance been declined, postponed, or increased in rate?
Is foreign travel or residence contemplated?
Details
Do you ever engage in hazardous sports, hobbies, or activities?
Have you ever been declined, postponed, or rated on a previous disability insurance application policy?
If yes, answered to any of the following questions, please provide details.
Question #
Date
Condition
Result
Question #
Date
Condition
Result
Question #
Date
Condition
Result
Have you consulted or been treated by a licensed physician, psychotherapist, psychologist, or other health care professional in the last 10 years? (other than routine checkup)
If yes, provide details
Provide details if you're taking prescription medication or taken prescription medication in the last 3 years
Medication Name
Dosage/Frequency
Reason for Medication
Medication Name
Dosage/Frequency
Reason for Medication
Medication Name
Dosage/Frequency
Reason for Medication
To the best of your knowledge, are you now in good health and free from mental or physical impairment, abnormality, injury, or disease?
If no, provide details
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Centennial, CO 80111

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