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Short-Term Disability Coverage Proposal 

* 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:
   
Client Information
*First Name
*Last Name
*Date of Birth
*State Lives
*State Works
* Gender Male
Female
* Tobacco Use? Yes
No
*Occupation
*Title
*Duties
*Annual Income (Net Income if Business Owner or Salary if Employee) $
*Bonus $
 Unearned $
Self-Employed or Business Owner
Yes
No
Years in Operation
% of Ownership
Type of Business
If less than 1 full tax year in business:
Former Occupation/Duties
Former Salary $
   
Short Term Case Design
Requested Benefit Amount $ -or- Max
Elimination Period: 
7 Days 14 Days
30 Days 60 Days
90 Days
The 3 Month Benefit Period is not available for the following state(s):
CT, IA, IL, NJ, VA
Benefit Period
3 Months 6 Months
1 Year 2 Years
   
Coverage InForce  (check all appropriate boxes)
Is there Short Term coverage in force? Yes No
Replacement percentage %
Benefit Cap or Maximum $
Elimination Period
Benefit Period
Who pays for the GLTD coverage?
Employee %
Employer %
Taxable Benefits Yes
No
Income covered:
(Check all that apply)
Salary
Overtime   
Bonus  
Commissions
Is there Individual disability coverage in force? Yes
No
Individual DI Carrier
Benefit Amount $
Elimination Period
Benefit Period
Who pays for the individual disability coverage?
Employee %
Employer %
Taxable Benefits Yes
No
   
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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