VA - Individual Disability Income

Impaired Risk Disability Income Quote Request

Broker Submitting Quote Request
First Name:		City
Last Name:		State
Company:		Zip
Street Address 1:		Phone#:
Street Address 2:		Fax#:
		E-Mail:

Clients Name:
Date of Birth:		Age:
Sex:
State of Residence:		State of Employment:
Is this client a smoker?
Has the proposed insured ever used any form of tobacco or nicotine based products or substitutes such as patches or gum?
If YES, please list type, amount per day and last date of use.
Occupation:		Title (if any):
Exact duties of client:

Does this client have any Disability Income Coverage presently in force? (Individual or Group)?
If Yes, please give details (amount and coverage)

Reported Income for Previous Year:
Reported Income two years ago (if known):
Monthly Income Benefit Amount Request
Elimination Period:
Benefit Period:
Please describe your client's medical or underwriting problem so that we can best recommend coverage.
Please list all Medications being taken with dosage.
Back or neck problems? Chiropractic treatment? When last?
Diabetes? Insulin Dependent? Age at Onset?
Hypertension Date of diagnosis? Last reading Date
Skin cancer or tumors? Type and location? Last treatment date
Drug and/or alcohol abuse? Type of drug Amount of alcohol?
Treatment dates Involvement in support groups Which?
How do you want the results sent to you by: Mail Fax E-Mail

If necessary we may contact you for additional
information before preparing your proposal.

Home Contact Us Our Team Resources Broker Tools Disclaimer
Life Insurance Disability Income Long Term Care Medicare Supplements Annuities Group Insurance Equity Based Products
Sub Standard Questionaires Sub Standard Articles Carrier Underwriting Requirements Additional Underwriting Resources
On-Line Annuity Quotes On-Line Term Quotes