AGENT INFORMATION Agent's Name (required) : Address : City (required) : State (required) : Zip Code (required) : Email Address (required) : Phone # (required) : Fax # : Broker / Dealer : Return Method : Fax Mail Broker Pick-Up Email CLIENT INFORMATION Client's Name : Birth Date : Gender : Male Female State : Tobacco Use : Yes No Job Title and Duties : Annual Income : Business Owner? : Yes No If Yes, Years of Ownership : # of Fulltime Employees : Existing Coverage : Individual Group Elimination Period :Benefit Period : PLAN DESIGN INFORMATION Plan Type : Personal Business Overhead Buy/Sell ELIMINATION PERIOD Personal :---30 day60 day90 day180 day365 day Business Overhead :---30 day60 day90 day180 day365 day Buy/Sell :---30 day60 day90 day180 day365 day BENEFIT PERIOD Personal :---3 month6 month12 month2 year5 year10 yearto age 65to age 67 Business Overhead :---12 month18 month24 month Buy/Sell :---3 month6 month12 month2 year5 year10 yearto age 65to age 67 MONTHLY BENEFIT Desired Amount : Quote Maximum : OPTIONAL BENEFITS Cola % : Other : Additional Information Please indicate any special health/underwriting considerations : A disability illustration cannot be provided unless this form is completely filled out Enter the code to prove you are human: