About Our Request Forms

Please click on the appropriate form listed below. Once completed, click SUBMIT and it will be sent directly to us.


Individual Long Term Disability/ Business Overhead Form

This form is for all Individual Long Term Proposals and all Business Overhead Expense cases.

Launch Form  


Buy Sell Proposal Request Form

This form is for Buy / Sell monthly, down payment, or lump sum benefit amount proposals.

Launch Form  


Multi-Life Offer Request Form

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.

Download our pre-formatted Excel spreadsheet census form below.

Required Excel Census Information:

  • Company Name and Address
  • Employee Name (First, Last)
  • Sex
  • DOB
  • Resident State
  • Occupation
  • Salary
  • Bonus/Commission

Once census is completed, please attach to form (links below) or email to [email protected].

Launch Form       Download Census Form (Excel)


Appointment Request Form

Let us take the application for you! A Live App Operator will contact you at the time requested to complete your Disability Insurance application. Appointments must be scheduled between 8:30AM and 4:30PM Central Time.

Launch Form  


Questions?

Please feel free to contact us at 800-945-9719 to discuss the case, underwriting concerns, program design, and competition and carrier selection.
General turn around time is within 24 hours for most Individual / Business Overhead and Buy-Sell requests.

Please allow additional time for Multi-Life requests.