Return to Requests for Proposal

Short-Term Disability Coverage Proposal 

* indicates Required input

DRG Rep.
Any Barbara Corton Benjamin K. Perez Bryan Orr James Brown Jeffrey J. Tabor John F. Nichols Kevin P. Cloutier Mose Richardson, Jr. Wade Payne
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
*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
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	$
Short Term Case Design
Requested Benefit Amount	$ -or- Max
Elimination Period:	14 Days 30 Days 60 Days 90 Days The 3 Month Benefit Period is not available for the following state(s): CT, IA, IL, NJ, VA
Benefit Period	3 Months 6 Months 1 Year 2 Years
Coverage InForce  (check all appropriate boxes)
Is there Short Term coverage in force?	Yes No
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