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*MaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920State 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?*YesNoIs there currently any individual disability insurance in force?*YesNoNot SureWho is the insurance company?*What is the monthly benefit amount?*Is there currently any group long disability insurance (LTD) in force?*YesNoNot SureMaximum 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?*YesNoIndustry*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.YesNoElimination Period30 Days60 Days90 Days180 Days365 DaysBenefit Period2 Year5 Year10 YearTo age 65To age 67To age 70Benefit Amount (or Maximum)Optional Riders Residual Cost of Living Adjustments (COLA) Future Purchase Options Catastrophic Benefit Retirement Protection