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Personal Information
Insured's Name (First, Last): Date of Birth:
Sex: Tobacco Use:   US Citizen / Green Card:  
Male   Female Yes   No Yes   No
Physical Address:
City:   State:   Zip:
Is the mailing address the same as the physical address? Y N
Mailing Address:
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:

How Did You Hear About Us?
Please check all that apply:
Search Engine Social Network Advertisement Family or Friend
Forum/Blog Co-Worker Other:

Employment Information
Employer: City/State: Occupation:
How Long Worked Here: Full Time (min 30 hrs wk): Actively working past 90 days:
Yes   No Yes   No
Job Duties: (Include title, duties, % of time in sales/travel/supervision etc. List any degrees and professional designations):
Base Salary (Net monthly): Commissions (Net monthly): Bonus/Other Incentive Compensation:
$ $ $
Monthly Retirement
Employer Match: Participant in Social Security/
recent statement:
$ % Yes   No
Annual Salary: 2 Years Ago: Annual Salary: 1 Year Ago: Annual Salary: This Year (Estimated):
$ $ $

Other Information
Other Earned Household Income (Monthly):
Source: Amount: $
Source: Amount: $
Unearned Income (Monthly):
Source: Amount: $
Source: Amount: $
Other Personal Information:
Any Recent Hospitalizations or Surgeries? (explain if Yes)
List Current Medications:
Existing disorders related to:
Musculoskeletal   Cardiovascular/Circulatory   Central Nervous System   Mental/ Psychiatric

Sources of Disability Income Insurance
Group Short Term Disability (GSTD)
Percentage of Salary: Maximum Benefit: Benefit Period (years): Waiting Period (days):
% $
Does GSTD include Bonus/other Incentive Compensation? Who is Premium Paid by:
Yes   No Company   Self
Group Long Term Disability (GLTD)
Percentage of Salary: Maximum Benefit: Benefit Period (years): Waiting Period (days):
% $
Does GLTD include Bonus/other Incentive Compensation? Who is Premium Paid by:
Yes   No Company   Self
Employer's policy regarding continued employment in the event
of a long term disability, if other than separation of services?

Other Individually Owned Disability Income Insurance Policy(ies)
  Policy #:   Carrier:
  Policy #:   Carrier:
  Policy #:   Carrier:

Assets / Expenses
  Assets:     Expenses:
Savings Value
(bank accounts, CDs, etc):
$ Mortgage/Rent: $
Investments Value
(stocks, mutual funds):
$ Home Owners Insurance: $
401K Value: $ Auto/Transportation: $
IRAs Value: $ Auto Insurance: $
Pension/Defined Benefit Value: $ Taxes: $
Other Tax Deferred
Instruments Value:
$ Life Insurance Premiums: $
Insurance Policies Cash Value: $ Disability Income Ins. Premiums: $
Total Savings/Retirement Assets: $ Health Insurance Premiums: $
Food: $
Primary Residence (Net Value): $ Utilities: $
Other Real Estate (Net Value): $ Education: $
Total Net Value Real Estate: $ Child Care/Elder Care: $
Credit Cards: $
Art/Jewelry (Appraised Value): $ Other Loan Payments: $
Other Assets: $ Other Monthly Expenses: $
Total Value Other Assets: $  
Total Assets (all sources): $ Total Monthly Expenses: $

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional
information where there was not enough fields above, please enter them here.

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