Disability Insurance Case Design Request - FPG

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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
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:
Benefit Period:
- 2 Years
- 5 Years
- to age 65
- to age 66/67
Benefit Riders:
Overhead Expense Policy Design
Monthy Benefit:
Elimination Periods:
Benefit Period:
- 12 Months
- 18 Months
- 24 Months
Benefit Riders:

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