VA - Individual Disability Income

Individual Disability Income

Individual Disability Income Insurance is extremely important.

It provides Income when Disability; due to Sickness or Accident destroys your client's ability to earn a regular income.

Please complete the following questionnaire to permit us to provide you with an Individual Disability Income Proposal:

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?
Occupation:		Title (if any):
Exact duties of client:
Is this client a government employee ?
Is this client the business owner?

Does this client have any In Force Disability Income Coverage presently (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:
Do you need supplies?
What supplies would you like?
Remarks:
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.