Return to Requests for Proposal

Individual / BOE 

* indicates Required input

DRG Rep.
Any Benjamin K. Perez Bryan Orr David A. Saltzman James Brown Jeffrey J. Tabor John F. Nichols Kevin P. Cloutier Mose Richardson, Jr. 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:
Client Information
*First Name
*Last Name
*Date of Birth
*State Lives	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
*State Works	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
* Gender	Male Female
* Tobacco Use?	Yes No
*Occupation
*Title
*Duties
*Years in current position
*Work from Home	Yes No
If Yes - % of time spent working at home	%
*Annual Income (Net Income if Business Owner or Salary if Employee)	$
*Bonus	$
Unearned	$
Self-Employed or Business Owner	Yes No
Years in Operation
% of Ownership
# of full time Employees
Type of Business	Sole Proprietor S-Corp C-Corp Partnership LLC LLP sole
If less than 1 full tax year in business:
Former Occupation/Duties
Former Salary	$
Individual Case Design
Requested Benefit Amount	$ -or- Max
Elimination Period:	14 Days 30 Days 60 Days 90 Days 180 Days 365 Days 720 Days
Benefit Period	6 Months 1 Year 2 Years 5 Years 10 Years To Age 65 To Age 67 To Age 70 Lifetime
Optional Riders	Own Occupation Residual/Partial Cost of Living Adjustment Catastrophic Benefit Future Purchase Option Automatic Increase Option Recovery Benefit Return of Premium
Retirement Completion Product	Yes No
Retirement Plan Income Deferral	$
Premium	Level Step Rate
Premium Payor	Employee Employer
Business Overhead Expense Case Design
Monthly Expenses	$
Requested Benefit Amount	$ -or- Max
Elimination Period:	30 Days 60 Days 90 Days
Benefit Period	12 Months 18 Months 24 Months
Optional Riders	Residential/Partial Professional Replacement Future Purchase Option Return of Premium
In force BOE Coverage Amount	$
Coverage InForce  (check all appropriate boxes)
Is there Group LTD coverage in force?	Yes No
Group LTD Carrier
Replacement percentage	%
Benefit Cap or Maximum	$
Elimination Period
Benefit Period
Who pays for the GLTD coverage?	Employee % Employer %
Taxable Benefits	Yes No
Income covered: (Check all that apply)	Salary Overtime    Bonus   Commissions
Is there Individual disability coverage in force?	Yes No
Individual DI Carrier
Benefit Amount	$
Elimination Period
Benefit Period
Who pays for the individual disability coverage?	Employee % Employer %
Taxable Benefits	Yes No
Is there competition on the case? If Yes, provide details
Medical Complications? (past 5 years)/ Medications taking? Height & Weight?
*I would like my proposal sent via...	Email    Fax    Overnight   Regular Mail