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Individual / BOE 

* indicates Required input
DRG Rep.
Producer Information
*Producer Name:
*Producer Company Name:
*Zip Code:
*Producer Broker Dealer or National Account Affiliation
  Send proposal to:
Client Information
*First Name
*Last Name
*Date of Birth
*State Lives
*State Works
* Gender Male
* Tobacco Use? Yes
*Years in current position 
*Work from Home Yes
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
Years in Operation
% of Ownership
# of full time Employees
Type of Business
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
Retirement Plan Income Deferral $
Premium Level
Step Rate
Premium Payor Employee
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
Income covered:
(Check all that apply)
Is there Individual disability coverage in force? Yes
Individual DI Carrier
Benefit Amount $
Elimination Period
Benefit Period
Who pays for the individual disability coverage?
Employee %
Employer %
Taxable Benefits Yes
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



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