Individual Disability Insurance Quote Request July 14, 2016 DIProtection If you have any questions or comments don’t hesitate to contact us directly at 602.616.5598 or jim@diprotection.com. Your Information (Advisor)Name* First Last Email* Phone Number*Your Client's InformationName* First Last Gender* Male Female Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920State of Residence*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificTobacco use in the last 12 months?* Yes No Is there currently any individual disability insurance in force?* Yes No Not Sure Who is the insurance company?* What is the monthly benefit amount?*Is there currently any group long disability insurance (LTD) in force?* Yes No Not Sure Maximum Monthly Benefit Cap?*Occupation?* Duties or Specialty? Annual Income? Include Salary, Commissions and Bonus*Why do we ask? Benefit amounts are based on a percentage of annual income. For business owners use net income.Business Owner or Self Employed?* Yes No Industry* Number of Employees?* Years in Operation?* CommentsList any association memberships (discounts may apply), medical conditions (including medications) or general comments that may applicableIndividual Case DesignDo you have a specific plan design?*If no, we will design what we feel is best given the situation. Yes No Elimination Period 30 Days 60 Days 90 Days 180 Days 365 Days Benefit Period 2 Year 5 Year 10 Year To age 65 To age 67 To age 70 Benefit Amount (or Maximum)Optional Riders Residual Cost of Living Adjustments (COLA) Future Purchase Options Catastrophic Benefit Retirement Protection