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Agent Name:

Agent Phone:

Email:

Client Name:

Date of Birth:

Tobacco Use:

yes

(Type: )

Height:

Weight:

State:

Gender:

Male

Female

Does the client have any medical history such as arthritis, fibromyalgia, cancer, back/spine problems, including Chiropractic care, heart or circulatory trouble, depression/anxiety, diabetes or any major surgeries? Include details of all health issues/surgeries along with medications: (date of diagnosis – dosage and frequency of medication)

Work 30+ hours per week?

yes

Work from home:

yes

- percentage of time: %

Occupation (Specialty if a physician)/Daily Duties:

Self-employed: # of Years

Percentage of ownership %

Net Annual Income $

Prior Year $

Number of full time Employees

Employee: # of Years

Gross Annual Income $

Prior Year

List any existing disability coverage whether individual or through an employer:

Please provide a quote for:

Benefit Amount

Maximum Available

(60% of annual income) &/or Specific Amount: $

Elimination Period:

180

365

Benefit Period:

To age 65/67

60 months

24 months

12 months

MEDICAL INFORMATION: ANY HISTORY OF:

Height:

Weight:

Please attach a list of current medications, both prescribed and over-the-counter, along with dosage and frequency. If you check “yes” to any items above, please provide a complete explanation of condition and treatment on a separate sheet of paper.

Additional riders requested:

Not all elimination and benefit period options are available in every state or with all carriers. The proposal will include available options A proposal will be based on the information you provide on this quote form. The proposal is not an offer of coverage but rather an estimate of what an underwriting decision may be based on limited information provided. All underwriting offers are tentative and subject to medical and financial review.

Email form to: crystal.clack@capitasfinancial.com

Cell: 913-787-7789

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Disability Quote Request Form

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