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The Brokers Source, LTD

Home Page
Request a Quote
Our Products
Our Carriers
Latest Resources
Licensing
TBS-EXPRESS
Contact

Disability Quote

Disability Insurance Quote Request

Request a Disability Insurance Quote

Step 1 of 3 - Agent Information

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Agent Information
Name
Phone
Fax
Email

Client Information
Name
Date of Birth
Month
Day
Year
Gender
- Male
- Female
State of Residence
Marital Status
Tobacco Use
- Yes
- No
Medical Information
Height
Weight
Medications and Dosages
In the last five years, has your client been treated for or received medical advice?
List details above
Employment Information
Occupation
Job Duties
Owns their own business?
- No
- Yes
Length of Employement
Works from home?
- No
- Yes
Work at home details
How many years have they owned their business?
How many employees?
Income Information

Income after business expenses but before taxes
Annual Salary
Bonus
Commission
Other Coverage Information
Does the client have any other disability benefits (including Std or Ltd)?
If yes, please list details including taxability of the benefit, benefit maximums, elmination period, etc.

Illustration Information
Elimination Period
Benefit Period
Would you like a proposal for Business Overhead Expense (BOE) coverage?
- No
- Yes
BOE Details
Please enter any details such as proposed insured's share of the monthly expenses.
Would you like a proposal for Buy Sell coverage?
- No
- Yes
Buy/Sell Coverage Details
Please list Buy/Sell coverage details including business value, trigger point, lump sum and monthly funding.
Optional Provisions
- Own Occupation
- Modified Own Occupation
- Cola 3%
- Cola 6%
- Residual/Partial
- Future Increase Option
- Return of Premium
- Catastrophic/ADL Rider
(not all riders are available on all products)
Special Instructions
Would you like us to suggest the one carrier we feel provides the best value for your client?
- Yes
- No
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