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Disability Insurance Quote
Colorado Insurance Group, LLC
Disability Questionnaire
SECTION I: AGENT INFORMATION
Full Name of Agent *
Address Line 1
Address Line 2
City, State, Zip
E-Mail *
Business Phone *
Cell Phone
Home Number
Fax Number
SECTION II: APPLICANT INFORMATION
Applicants Name:
Date of Birth
Sex:
Male
Female
Resident State:
State written:
Does the applicant use tobacco?:
None
Cigarette
Cigar
Chew
Occupation (If not currently employed, explain i.e. Retired, Disabled, Social Security Disability, Workmans Comp)
Specific Job Duties:
Annual income:
Self-Employed?
Yes
No
Any existing individual or group coverage?
Yes
No
If yes, please provide details of coverage:
Who will be paying for the coverage?
Individual
Employer
SECTION III: BENEFIT INFORMATION
Type of coverage?
Individual Coverage
Business Overhead Expense
Business Disability Buy-Out Insurance
Monthly benefit:
Elimination Period
30 Days
60 Days
90 Days
180 Days
365 Days
730 Days
Benefit Period
2 Years
5 Years
Age 65
Rider(s)
Residual (Partial Earning Loss)
Future Purchase Options
C.O.L.A.
Non-Cancelable
Own Occupation
Social Insurance
SECTION IV: CASE INFORMATION
Are you in competition for this case?
Yes
No
I don’t know
If yes, please specify:
Additional comments? Any health concerns? Known medications?
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