Buy Sell Proposal Request Form

* Indicates Required Input

DRG Rep.
Any Benjamin K. Perez James Brown Jeffrey J. Tabor John F. Nichols Kevin P. Cloutier Rick Fitzke
Producer Information
*Producer Name:
*Producer Company Name:
*Address:
*City:
*State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip Code:
*Phone:
*Fax:
*Email:
*Producer Broker Dealer or National Account Affiliation
Send Proposal To:
Case Information
*Business Name:
*State Located:
*Type of Industry:
*Years in Operation:
Type of Entity:	Personal Services Professional Services Non-Service Business
Owners
Name Gender Tobacco DOB Duties Income % Owner Benefit Amount *1 M F % $ 2 M F % $ 3 M F % $ 4 M F % $ 5 M F % $ 6 M F % $ 7 M F % $ 8 M F % $ 9 M F % $ 10 M F % $ Less than 10% ownership or more than 10 partners will not be considered for Buy/Sell coverage.
Case Design
*Total Business Value:	$
*Benefit Payment Options	Lump Sum   Payout Options Monthly Installment $ 2 Years 3 Years 5 Years Down Payment $ 2 Years 3 Years 5 Years
*Elimination Period:	365 Days 540 Days 730 Days
Future Purchase Option	Yes No
Other Case Design Info:
If any owners currently have Buy Sell coverage inforce, please indicate who and how much:
Replacing:	Yes No
Is There Competition in the Case?	Yes No
If Yes, Provide Details:
Check with underwriting regarding the following medical conditions: