WHAT WE DO
HOW WE DO IT
WHO WE SUPPORT
ABOUT
CONTACT
REGISTER
LOG IN
Disability Insurance Case Design
Complete this form to have FPG find your client the best Disability Insurance Solution
Agent Name:
*
First
Last
Phone
*
Email
*
Client's Information
Client Name:
*
Date of Birth:
*
Month
Day
Year
Gender:
*
Female
Male
Tobacco User:
*
Yes
No
Client State:
*
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Net Annual Income
*
Occupation:
*
Occupation Duties:
*
Work at Home:
*
Yes
No
% of Time Working from Home (if applicable):
Company Name:
Number of Employees:
Years in Business:
Entity Type:
Business Owner/Self-Employed
C-Corp
Government Employee:
Yes
No
Years of Government Employment (if applicable):
Government Type (if applicable):
Federal
State
County
City
Group LTD in-force?
Yes
No
Monthly Amount:
Percentage:
60%
67%
Employer Paid:
Yes
No
Individual Coverage In-Force
Yes
No
Monthly Amount:
To Remain In-Force?
Yes
No
Any medical issues or other comments? (if applicable)
Individual Disability Policy Design
Who will pay the premiums?
Employer
Employee
Monthly Benefits:
Elimination Periods:
60
90
180
365
Benefit Period:
2 Years
5 Years
to age 65
to age 66/67
Benefit Riders:
SSIB
CAT
Residual Benefits
COLA
Non-Cancelable
Return of Premium
Own Occ.
Future Purchase Option
No Riders
Overhead Expense Policy Design
Monthy Benefit:
Elimination Periods:
30 Days
60 Days
90 Days
Benefit Period:
12 Months
18 Months
24 Months
Benefit Riders:
Residual Benefits
Future Purchase Option
Δ
WHAT WE DO
HOW WE DO IT
WHO WE SUPPORT
ABOUT
CONTACT
REGISTER
LOG IN
X