Multi-Life Proposal Request Form "*" indicates required fields Use this form for cases with three or more lives and for which you would like to propose an executive carve out program, a retirement completion program, a group supplement program, or other type of multi-life disability income benefit program. This form will allow us to negotiate/request Guarantee Issue or Simplified offers from the insurance carriers. Additionally, a census in an Excel Spreadsheet is required.Click here to download the Excel Census Form.Once completed, please attach below or e-mail to [email protected].* = Required FieldsContact InformationToday's Date* MM slash DD slash YYYY Name* First Last Phone*Email* Producer Name* Firm* Case InformationEmployer Name* Nature of Business* Year Established* Principal Location:City and State Other LocationsEntity Type:* C-Corp S-Corp Sole Proprietor Partnership LLC LLP PA PC Total Number of Full-Time Employees:* Number of Full-Time Employees to be Considered for Coverage:* Employees To Be Covered: All Full-Time Employees Describe Eligible Cases Please Describe Eligible Cases:Are you aware of anyone in the group who has been declined for Life or Disability Insurance?* Yes No If Yes, please describe:Other CoverageOther Coverage:*Reveals additional sections below. If none, check here LTD Employer Sponsored Ind. Coverage LTDLTD Carrier E.P. B.P. Percent Max Benefit LTD Covers: Salary Bonus Commissions Pension Contributions Premium Paid By: Employer Employee Split Split % Benefits Taxable? Yes No Employer Sponsored Ind. CoverageCarrier E.P. B.P. Benefit Premium Paid By: Employer Employee Split Split % Benefits Taxable? Yes No Requested GSI Case DesignGSI Premium Payor Employer Employer Gross-Up Employee Split Split % Income Sources To Be Covered: Salary Bonus Commissions Pension Contributions Will GSI coverage replace or supplement existing LTD ? Replace Supplement Desired Effective Date: MM slash DD slash YYYY GSI Benefit:Benefit Dollar ($) Amount: Policy: E.P.: Benefit Period: MNDA: Definition of Disability: Residual: CAT: COLA: SIS: Attach Census:Click here to download the Excel Census Form.Once completed, please attach here or e-mail to [email protected]. Drop files here or Select files Max. file size: 50 MB. Comments / Other Requests:Spam Prevention