Individual Long Term Disability/ Business Overhead Form "*" indicates required fields This form is for all Individual Long Term Proposals and all Business Overhead Expense cases. Please complete the form below to submit your request.* = Required FieldsProducer InformationProducer Name:* First Last Company Name, Broker Dealer, or National Account Affiliation:* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:*Email:* Send proposal to: Client InformationName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920State Lives*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificGender* Male Female Tobacco Use?* Yes No Occupational HistoryCurrent Occupation* Government Employee?* Yes No Government Employee Type* Federal State Other If "other," please choose "other" and specify in the box provided above.How many years as a government employee?*Self-Employed, Business Owner, or 1099?* Yes No Years in Operation* % of Ownership* Number of full time employees:* Type of Business*Sole ProprietorS-CorpC-CorpPartnershipIf Less Than 1 Full Year in Self Employment:Former Occupation/DutiesFormer Salary(Past two years)Duties in Current PositionDuties in Current Position*Please include description and % of time, if any manual duties.Years in Current Position* Annual Income*(NET Income if Business Owner/Self-Employed/1099)Bonus / Commissions(Need two year average)Stock Options / RSUs(Need three year average already paid to include)Unearned Income(Rental Income, Interest, Dividends, Capital Gains)Individual Case DesignRequested Monthly Benefit Amount Maximum Monthly Benefit Amount$999,999.99 is the maximum monthly benefit amount you may request on this form.Elimination Period 30 Days 60 Days 90 Days 180 Days 365 Days Benefit Period 6 Months 1 Year 2 Years 5 Years 10 years To Age 65 To Age 67 To Age 70 Optional Riders True Own Occupation Residual/Partial Cost of Living Adjustment Catastrophic Benefit Future Purchase Option Automatic Increase Option Retirement Plan Protection Premium Payor Employee Employer Coverage In Force(All visible fields are required)Is there Group LTD coverage in force?* Yes No Replacement Percentage* Monthly Benefit Cap*Elimination Period* Benefit Period* Taxable Benefits* Yes No Combo Combo - % Employer Paid*Combo - % Employee Paid*Income Covered* Salary Only All Compensation Is there individual disability coverage in force?* Yes No Individual DI Carrier* Monthly Benefit Amount*Elimination Period* Benefit Period* Taxable Benefits* Yes No Combo Combo - % Employer Paid*Combo - % Employee Paid*Replacing? Yes No Business Overhead Expense Case DesignMonthly ExpensesRequested Benefit Amount Maximum Monthly Benefit AmountPlease enter a number from 0 to 999999.99.$999,999.99 is the maximum monthly benefit amount you may request on this form.Elimination Period 30 Days 60 Days 90 Days Benefit Period 12 Months 18 Months 24 Months Optional Riders Residential/Partial Future Purchase Option In force BOE Coverage AmountReplacing? Yes No Additional InformationMedical Complications?*Past 5 years. Medications taking? Height & Weight?Any special notes? Competition? Carrier preference?Spam Prevention