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Return to Requests for Proposal

Multi-Life Offer Request Form

* Indicates Required Input
DRG Rep.
 
Producer Information
*Producer Name:
*Producer Company Name:
*Address:
*City:
*State:
*Zip Code:
*Phone:
*Fax:
*Email:
*Producer Broker Dealer or National Account Affiliation
Send Proposal To:
   
Case Information
*Case Name:
*Date by which Offer is Needed:
*Effective Date of Coverage:
*Main Location City:
*Main Location State:
*Other Locations and States:
*How long has this business been in operation?
*Nature of Business:
Type of entity:

C-Corp
S-Corp
Partnership
LLC
LLP

*Total Number of Employees:
*Number to be Considered for Offer:
SIC#
*Occupations (Nature of 'ee group) to be Considered:
Premium Payer:  
*Employer %
*Employee %
*Proposed DI Effective Date?
   
Multilife 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
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
   
Coverage In-Force
*Check all that apply:

Individual
Group LTD
Combination
None
Group LTD
Carrier Name:
Replacement: %
Benefit Maximum: $
Taxable Benefit Non-Taxable Benefit:
Income Covered: Salary
Overtime
Bonus
Commissions
Pension Contributions
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
Individual DI
Benefit Amount $
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
Taxable Benefit Non-Taxable Benefit
   
Other Information

Is there competition on the case?

Yes No
If yes, provide details:
Are you aware of any individuals listed on the census that has significant medical history?
Any special considerations we should be aware of?
Your Marketing plans are important to our consideration of an offer. Describe how this offer will be communicated to all employees:
   
 

 

 
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