Disability Quote Step 1 of 8 - Agent Information0%Name* First Last TitleBusiness NameUse address of record YesMailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneFax NumberEmail* Name First Last Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexMaleFemailTobacco UserYesNoIf Yes, Describe UsageState of ResidenceOccupationJob Duties(be specific & include percent of time spent on each duty)Current Salary(use Net Income if self-employed)Additional IncomeUnearned IncomeCoverageNoneIndividualGroupIF your client has BOTH group and individual coverage, put one set of info below and the other in the Additional Information box below.Premium Paid ByEmployeeEmployerBenefit Amount or Percent of IncomeMonthly CapElimination Period30 Days60 Days90 Days180 Days365 DaysOtherIf other indicate how many daysBenefit Period2 Years5 YearsTo age 65Basic AmountSISTotal Monthly BenefitRequest max base only YesRequest max base with SIS combination YesElimination Period30 Days60 Days90 Days180 Days365 DaysBenefit Period2 Years5 YearsTo age 65Monthly ExpensesElimination Period30 Days60 Days90 DaysBenefit Factor12 Times18 Times24 TimesBusiness ValuePercent of OwnershipElimination Period365 Days540 Days730 DaysPayment MethodLump SumMonthly InstallmentsCombinationAdditional Riders* Cost of Living Benefit Increase Residual Disability Extended Benefit Period Return To Work Regular Occupation* all riders are not available in all occupation classesGoal We Would Like To MeetThis Illustration Is Needed ByMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I Would Like My Request Sent By E-mail Fax Mail