AIS Disability Proposal Request Form
Advisor Information
Advisor Name
Firm Name
Today's Date
Email Address
Phone Number
Client Information
Client Name
Date of Birth
Gender
Male
Female
Tobacco Use
Yes
No
State
Annual Income
Pension Income
Occupation
Work @ Home
Yes
No
% of Time
Occupational Duties
Company Type
Business Owner/Self Employed
C-Corporation
S-Corp/LLC
# of Employees
Years in Business
Gov't Employee
Yes
No
# of Years as Government Employee
Gov't EE Type
Federal
State
County
City
Group LTD Inforce?
Yes
No
If Yes - Monthly Amount
60%
67%
Employer Paid
Yes
No
Individual Coverage Inforce?
Yes
No
If Yes - Monthly Amount
To Remain Inforce
Yes
No
Medical Issues or Other Comments
Individual Disability Policy Design
Who Will Pay the Premium?
Employee
Employer
Specified Monthly Benefit or Max:
Benefit Riders
SSIB
Residual Benefits
Non-Cancelable
Return of Premium
Own Occupation
Future Purchase Option
Auto Increase Benefit
No Riders
Elimination Period
Please select...
30 Days
60 Days
90 Days
180 Days
365 Days
Benefit Period
Please select...
2 Years
5 Years
To Age 65
To Age 66/67
Overhead Expense Policy
Monthly Benefits:
Elimination Period
Please select...
30 Days
60 Days
90 Days
Benefit Period
Please select...
12 Months
18 Months
24 Months
Benefit Riders
Residual Benefits
Future Purchase Option
Are you licensed in the State you are applying
Yes
No (if No, please contact Insurance team. You will need to be licensed BEFORE application)
Are you contracted with the Disability product that you would like to apply?
Yes
No (if No, please contact Insurance team.)
Contact Information