Salary Continuation
Producer Information
Your Name
*
:
Agency Name:
Phone
:
Email
*
:
Presenting Producer:
Client Information
Client's Name:
First
MI
Last
Title
Client’s DOB
:
January
February
March
April
May
June
July
August
September
October
November
December
,
Age
*
:
Height:
ft
in
Weight:
lbs
State
*
:
File does not exist
Occupation (Specialty)
*
:
Earned Income ($/year):
Current Disability Insurance in Force ($/year):
Coverage Information
Temporary Total Disability
Desired Monthly Benefit:
$
Benefit Period:
12 months
36 months
60 months
84 months
24 months
48 months
72 months
Elimination Period:
30 days
60 days
90 days
180 days
365 days
730 days
Options:
COLA Rider
Residual Disability Rider
(Permanent Disability
/Lump Sum Benefit will be quoted on Proposal if available.)
Permanent Total Disability
Desired Total Benefit:
$
(type MAX to request maximum allowable coverage)
Elimination Period:
6 months
24 months
60 months
12 months
36 months
18 months
48 months
Comments regarding health issues or other underwriting
consideration issues:
* required fields