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Buy Sell Proposal Request Form

* Indicates Required Input
DRG Rep.
 
Producer Information
*Producer Name:
*Producer Company Name:
*Address:
*City:
*State:
*Zip Code:
*Phone:
*Fax:
*Email:
*Producer Broker Dealer or National Account Affiliation
  Send Proposal To:
   
Case Information
*Business Name:
*State Located:
*Type of Industry:
*Years in Operation:
Type of Entity: Personal Services
Professional Services
Non-Service Business
Owners
  Name Gender Tobacco DOB Duties Income % Owner Benefit Amount
*1 %
$
2 %
$
3 %
$
4 %
$
5 %
$
6 %
$
7 %
$
8 %
$
9 %
$
10 %
$
Less than 10% ownership or more than 10 partners will not be considered for Buy/Sell coverage.
   
Case Design
*Total Business Value: $
*Benefit Payment Options
Lump Sum   Payout Options
Monthly Installment $ 2 Years 3 Years 5 Years
Down Payment $ 2 Years 3 Years 5 Years
*Elimination Period: 365 Days
540 Days
730 Days
Future Purchase Option Yes
No
Other Case Design Info:
If any owners currently have Buy Sell coverage inforce, please indicate who and how much:
Replacing: Yes
No
Is There Competition in the Case? Yes
No
If Yes, Provide Details:
Check with underwriting regarding the following medical conditions:
   
 
   

 

 

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