DISABILITY INCOME QUOTE Broker Information Date Proposal to be: FaxedMailedE-mailed Name Company Address E-mail Phone Number Fax Number Client Name Date of Birth Sex MaleFemale Smoker YesNo Occupation Income Specific Job Duties/Speciality Business Owner YesNo Number of Employees Years In Business Premium EE PayER Pay State of Issue Current coverage in force Current carrier of in force coverage Replace YesNo Group Coverage Benefit Quote Information Individual Monthly Benefit Elimination Period 60 days90 days180 days365 days Benefit Period 2 Years5 YearsTo age 65/67 Benefit Options ResidualCOLA 3% or 6% Future Increase Option Business Overhead Monthly Benefit Elimination Period 60 days90 days180 days365 days Benefit Period 12 months18 months24 months Disability Buy-Out Monthly Benefit Elimination Period 12 months18 months24 months Funding Method MonthlyLump SumCombination
