Individual Disability Insurance Quote Request – Disability Protection Partners

Your Information (Advisor)

Name*

First Last

Email*

Phone Number*

Name*

First Last

Gender*

Date of Birth*

State of Residence*

Tobacco use in the last 12 months?*

Is there currently any individual disability insurance in force?*

Who is the insurance company?*

What is the monthly benefit amount?*

Is there currently any group long disability insurance (LTD) in force?*

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?*

Industry*

Number of Employees?*

Years in Operation?*

Comments

List any association memberships (discounts may apply), medical conditions (including medications) or general comments that may applicable

Do you have a specific plan design?*

If no, we will design what we feel is best given the situation.

Elimination Period

Benefit Period

Benefit Amount (or Maximum)

Optional Riders