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Long Term Disability Insurance Request
Advisor Name
First Name
Last Name
Email
Personal Information
Client Name
First Name
Last Name
DOB
MM
DD
YYYY
Gender
Male
Female
State
Select State
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Delaware - DE
Florida - FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Tobacco user?
Yes
No
Employment Information
Occupation
Employer
Job Duties
Base Salary
$
Bonus
$
Commission Income
$
Current Group Coverage
% of Salary
Maximum Monthly Benefit
Select Benefit Period
2 Years
5 Years
10 Years
to 65
to 67
Select Waiting Priod
90 days
180 days
365 days
Coverage is paid for by
Employer (pre-tax)
Self (post-tax)
Other existing coverage
Desired Coverage
Coverage Amount Requested
Benefit Period Requested
2 years
5 years
10 years
to 65
to 67
Waiting Period Requested
0 days
90 days
180 days
365 days
Additional Riders
Residual Disability Benefit
Cost of Living Adjustment
Regular Occupation
Benefit Increase
Catastrophic
Underwriting Considerations
Musculoskeletal
Cardiovascular/Circulatory
Central Nervous System
Mental/Psychiatric
Other
Additional details or considerations
Thank you!
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