Disability Income Illustration Request
Broker
Broker Name
Date
Address
Fax
Phone
Email
Client
Insured's Name
DOB
State
Sex
Male
Female
Tobacco
Yes
No
Tobacco Type & Frequency
Occupation
Self Employed
Yes
No
% owned
Industry
Specific Duties
Work from Home
Yes
No
% of time
Field Duties
Yes
No
% of time
Health Conditions if any
(details in remarks)
Base Benefits
Benefit Approach
Employee Pay
Employer Pay
Specific Amount or Maximum Available
Annual Earned Income (Gross)
Existing DI Coverage
Existing LTD Coverage
Waiting Period
30
60
90
180
360
Benefit Period
To Age 65
24 Months
60 Months
Mode of Payment
Annual
Semi-Annual
Quarterly
Monthly
Additional Benefits - Check box or enter amount of rider if applicable
Future Purchase Option
- or - $
Residual
Social Security Integration
- or - $
COLA
3%
6%
Additional Remarks